Bringing Hospital and Community Together: Interventions to Bridge the Transitional Care Gap

Abstract Problem As healthcare spending continues to increase and overall quality lags in comparison to other developed countries, hospital readmission has been targeted to increase quality while decreasing cost. Components of the Affordable Care Act (ACA) have placed an emphasis on preventative and transitional care which has created programs aimed at reducing readmission, including the Community Health Access Programs (CHAP). One program in St. Louis, Missouri consisted of advanced practice paramedics and an occupational therapy assistant that performed discharge follow-up through in-home, in-office, and telephone visits. An in-depth program evaluation can create a foundation to build other programs in communities suffering similar care gaps. Methods A retrospective, program evaluation was performed. Data compilation revealed 22 patients who received services from the CHAP at Christian Hospital after a hospitalization. Age, race, gender, length of stay, number of secondary diagnoses. number of CHAP visits, and days to readmission from discharge were provided. A group of 22 patients not receiving CHAP services was then formed. Results The mean LOS for the CHAP group was 5.95 days and for the non-CHAP group was 5.36 days. There was no significant difference in the two groups for LOS. For days to readmission the average was 17.41 days for the CHAP group and 12.18 days for the non-CHAP group which approached statistical significance (p = 0.056). A linear regression comparing number of CHAP visits found that the number of CHAP visits was associated with more days before the next admission. Implications for Practice Findings suggest the CHAP was able to improve readmission rates as the number of patient visits increased. This suggests patients need more connection with providers than is typically occurring in areas without a transitional care program in place. Further analysis is needed to determine implications across in other communities and across other diagnoses

Pressure-driven fragmentation of clouds at high redshift

The discovery of a hyper metal-poor star with total metallicity of $\le 10^{-5}$ Z$_\odot$, has motivated new investigations of how such objects can form from primordial gas polluted by a single supernova. In this paper we present a shock-cloud model which simulates a supernova remnant interacting with a cloud in a metal-free environment at redshift $z=10$. Pre-supernova conditions are considered, which include a multiphase neutral medium and H II region. A small dense clump ($n=100$ cm$^{-3}$), located 40 pc from a 40 M$_\odot$ metal-free star, embedded in a $n=10$ cm$^{-3}$ ambient cloud. The evolution of the supernova remnant (explosion energy $10^{52}$ erg) and its subsequent interaction with the dense clump is examined. This is the first study to include a comprehensive treatment of the non-equilibrium chemistry and associated radiative cooling that is occurring at all stages of the shock-cloud model. We have included a primordial chemistry network that covers the temperature range $10-10^9$ K, and is coupled to thermal models of atomic & molecular cooling. We find $\times10^{3}$ density enhancement of the clump (i.e maximum density $\sim 78000$ cm$^{-3}$) within this metal-free model. This is consistent with Galactic shock-cloud models considering solar metallicity gas with equilibrium cooling functions. Despite this strong compression, the cloud does not become gravitationally unstable. We find that the small cloud modelled here is destroyed for shock velocities $\gtrsim 50\,$km s$^{-1}$, and not significantly affected by shocks with velocity $\lesssim 30\,$km s$^{-1}$. Rather specific conditions are required to make such a cloud collapse.Comment: accepted in MNRAS, 11 pages, 5 figures, 5 table

trans-Complementation of an NS2 Defect in a Late Step in Hepatitis C Virus (HCV) Particle Assembly and Maturation

Recent studies using cell culture infection systems that recapitulate the entire life cycle of hepatitis C virus (HCV) indicate that several nonstructural viral proteins, including NS2, NS3, and NS5A, are involved in the process of viral assembly and release. Other recent work suggests that Ser-168 of NS2 is a target of CK2 kinase–mediated phosphorylation, and that this controls the stability of the genotype 1a NS2 protein. Here, we show that Ser-168 is a critical determinant in the production of infectious virus particles. Substitution of Ser-168 with Ala (or Gly) ablated production of infectious virus by cells transfected with a chimeric viral RNA (HJ3-5) containing core-NS2 sequences from the genotype 1a H77 virus within the background of genotype 2a JFH1 virus. An S168A substitution also impaired production of virus by cells transfected with JFH1 RNA. This mutation did not alter polyprotein processing or genome replication. This defect in virus production could be rescued by expression of wt NS2 in trans from an alphavirus replicon. The trans-complementing activities of NS2 from genotypes 1a and 2a demonstrated strong preferences for rescue of the homologous genotype. Importantly, the S168A mutation did not alter the association of core or NS5A proteins with host cell lipid droplets, nor prevent the assembly of core into particles with sedimentation and buoyant density properties similar to infectious virus, indicating that NS2 acts subsequent to the involvement of core, NS5A, and NS3 in particle assembly. Second-site mutations in NS2 as well as in NS5A can rescue the defect in virus production imposed by the S168G mutation. In aggregate, these results indicate that NS2 functions in trans, in a late-post assembly maturation step, perhaps in concert with NS5A, to confer infectivity to the HCV particle

The potential for circular dichroism as an additional facile and sensitive method of monitoring low-molecular-weight heparins and heparinoids

The ultraviolet circular dichroism (CD) spectra of commercial low-molecular-weight heparins, heparinoids and other anticoagulant preparations have been recorded between 180 and 260 nm. Principal component analysis of the spectra allowed their differentiation into a number of groups related to the means of their production reflecting the structural changes introduced by each process. The findings suggest that CD provides a complementary technique for the rapid analysis of heparin preparations

Heparan sulfate regulates amyloid precursor protein processing by BACE1, the Alzheimer's β-secretase

Cleavage of amyloid precursor protein (APP) by the Alzheimer's β-secretase (BACE1) is a key step in generating amyloid β-peptide, the main component of amyloid plaques. Here we report evidence that heparan sulfate (HS) interacts with β-site APP-cleaving enzyme (BACE) 1 and regulates its cleavage of APP. We show that HS and heparin interact directly with BACE1 and inhibit in vitro processing of peptide and APP substrates. Inhibitory activity is dependent on saccharide size and specific structural characteristics, and the mechanism of action involves blocking access of substrate to the active site. In cellular assays, HS specifically inhibits BACE1 cleavage of APP but not alternative cleavage by α-secretase. Endogenous HS immunoprecipitates with BACE1 and colocalizes with BACE1 in the Golgi complex and at the cell surface, two of its putative sites of action. Furthermore, inhibition of cellular HS synthesis results in enhanced BACE1 activity. Our findings identify HS as a natural regulator of BACE1 and suggest a novel mechanism for control of APP processing

Deriving Multiple Benefits from Carbon Market-Based Savanna Fire Management: An Australian Example

Carbon markets afford potentially useful opportunities for supporting socially and environmentally sustainable land management programs but, to date, have been little applied in globally significant fire-prone savanna settings. While fire is intrinsic to regulating the composition, structure and dynamics of savanna systems, in north Australian savannas frequent and extensive late dry season wildfires incur significant environmental, production and social impacts. Here we assess the potential of market-based savanna burning greenhouse gas emissions abatement and allied carbon biosequestration projects to deliver compatible environmental and broader socio-economic benefits in a highly biodiverse north Australian setting.Drawing on extensive regional ecological knowledge of fire regime effects on fire-vulnerable taxa and communities, we compare three fire regime metrics (seasonal fire frequency, proportion of long-unburnt vegetation, fire patch-size distribution) over a 15-year period for three national parks with an indigenously (Aboriginal) owned and managed market-based emissions abatement enterprise. Our assessment indicates improved fire management outcomes under the emissions abatement program, and mostly little change or declining outcomes on the parks. We attribute improved outcomes and putative biodiversity benefits under the abatement program to enhanced strategic management made possible by the market-based mitigation arrangement.For these same sites we estimate quanta of carbon credits that could be delivered under realistic enhanced fire management practice, using currently available and developing accredited Australian savanna burning accounting methods. We conclude that, in appropriate situations, market-based savanna burning activities can provide transformative climate change mitigation, ecosystem health, and community benefits in northern Australia, and, despite significant challenges, potentially in other fire-prone savanna settings

Estimating Nosocomial Infection and its Outcomes in Hospital Patients in England with a Diagnosis of COVID-19 Using Machine Learning

BACKGROUND: COVID-19 nosocomial infections (NIs) may have played a significant role in the dynamics of the pandemic in England, but analysis of their impact at the national scale has been lacking. Our aim was to provide a comprehensive account of NIs, identify their characteristics and outcomes in patients with a diagnosis of COVID-19 and use machine learning modelling to refine these estimates. METHODS: From the Hospital Episodes Statistics database all adult hospital patients in England with a diagnosis of COVID-19 and discharged between March 1st 2020 and March 31st 2021 were identified. A cohort of suspected COVID-19 NIs was identified using four empirical methods linked to hospital coding. A random forest classifier was designed to model the relationship between acquiring NIs and the covariates: patient characteristics, comorbidities, frailty, trust capacity strain and severity of COVID-19 infections. FINDINGS: In total, 374,244 adult patients with COVID-19 were discharged during the study period. The four empirical methods identified 29,896 (8.0%) patients with NIs. The random forest classifier estimated a mean NI rate of 10.5%, with a peak close to 18% during the first wave, but much lower rates thereafter and around 7% in early spring 2021. NIs were highly correlated with longer lengths of stay, high trust capacity strain, greater age and a higher degree of patient frailty. NIs were also found to be associated with higher mortality rates and more severe COVID-19 sequelae, including pneumonia, kidney disease and sepsis. INTERPRETATION: Identification of the characteristics of patients who acquire NIs should help trusts to identify those most at risk. The evolution of the NI rate over time may reflect the impact of changes in hospital management practices and vaccination efforts. Variations in NI rates across trusts may partly reflect different data recording and coding practice

3D Line Radiative Transfer & Synthetic Observations with Magritte

Electromagnetic radiation is a key component in many astrophysical simulations. Not only does it dictate what we can or cannot observe, it can provide radiation pressure, efficient heating and cooling mechanisms, and opens up a range of new chemical pathways due to photo-reactions. Magritte is a software library that can be used as a general-purpose radiative transfer solver, but was particularly designed for line radiative transfer in complex 3D morphologies, such as, for instance, encountered in the stellar winds around evolved stars (see Decin, 2020). It is mainly written in C++ and can either be used as a Python package or as a C++ library. To compute the radiation field, a deterministic ray-tracer and a formal solver are employed, i.e., rays are traced through the model and the radiative transfer equation is solved along those rays (De Ceuster et al., 2019). This is in contrast to most radiative transfer solvers which employ (probabilistic) Monte Carlo techniques (Noebauer & Sim, 2019). By virtue of minimal assumptions about the underlying geometric structure of a model, Magritte can handle structured and unstructured input meshes, as well as smoothed-particle hydrodynamics (SPH) data. Furthermore, tools are provided to optimise different input meshes for radiative transfer (De Ceuster et al., 2020)