Can switching fuels save water? A life cycle quantification of freshwater consumption for Texas coal-and natural gas-fired electricity

Thermal electricity generation is a major consumer of freshwater for cooling, fuel extraction and air emissions controls, but the life cycle water impacts of different fossil fuel cycles are not well understood. Much of the existing literature relies on decades-old estimates for water intensity, particularly regarding water consumed for fuel extraction. This work uses contemporary data from specific resource basins and power plants in Texas to evaluate water intensity at three major stages of coal and natural gas fuel cycles: fuel extraction, power plant cooling and power plant emissions controls. In particular, the water intensity of fuel extraction is quantified for Texas lignite, conventional natural gas and 11 unconventional natural gas basins in Texas, including major second-order impacts associated with multi-stage hydraulic fracturing. Despite the rise of this water-intensive natural gas extraction method, natural gas extraction appears to consume less freshwater than coal per unit of energy extracted in Texas because of the high water intensity of Texas lignite extraction. This work uses new resource basin and power plant level water intensity data to estimate the potential effects of coal to natural gas fuel switching in Texas’ power sector, a shift under consideration due to potential environmental benefits and very low natural gas prices. Replacing Texas’ coal-fired power plants with natural gas combined cycle plants (NGCCs) would reduce annual freshwater consumption in the state by an estimated 53 billion gallons per year, or 60% of Texas coal power’s water footprint, largely due to the higher efficiency of NGCCs.Mechanical Engineerin

Adherence to pediatric diabetic ketoacidosis guidelines by community emergency departments' providers

Background: Diabetic ketoacidosis (DKA) is a common presentation of type I diabetes mellitus to the emergency departments. Most children with DKA are initially managed in community emergency departments where providers may not have easy access to educational resources or pediatric-specific guidelines and protocols that are readily available at pediatric academic medical centers. The aim of this study is to evaluate adherence of community emergency departments in the state of Indiana to the pediatric DKA guidelines. Methods: We performed a retrospective chart review of patients, age 18 years of age or under, admitted to the pediatric intensive care unit with a diagnosis of DKA. Results: A total of 100 patients were included in the analysis. Thirty-seven percent of patients with DKA were managed according to all six guideline parameters. Only 39% of patients received the recommended hourly blood glucose checks. Thirty percent of patients received intravenous insulin bolus, which is not recommended. Conclusions: Non-adherence to pediatric DKA guidelines still exists in the state of Indiana. Further, larger studies are needed to reveal the etiology of non-adherence to pediatric DKA guidelines and strategies to improve that adherence

Measuring success: perspectives from three optimization programs on assessing impact in the age of burnout

Electronic health record (EHR) optimization has been identified as a best practice to reduce burnout and improve user satisfaction; however, measuring success can be challenging. The goal of this manuscript is to describe the limitations of measuring optimizations and opportunities to combine assessments for a more comprehensive evaluation of optimization outcomes. The authors review lessons from 3 U.S. healthcare institutions that presented their experiences and recommendations at the American Medical Informatics Association 2020 Clinical Informatics conference, describing uses and limitations of vendor time-based reports and surveys utilized in optimization programs. Compiling optimization outcomes supports a multi-faceted approach that can produce assessments even as time-based reports and technology change. The authors recommend that objective measures of optimization must be combined with provider and clinician-defined value to provide long term improvements in user satisfaction and reduce EHR-related burnout

Before the Flood: Impact of Coordination of Care and Direct Admissions on Emergency Department Volumes

Background: Transfers of pediatric patients occur to access specialty and subspecialty care, but incur risk, and consume resources. Direct admissions to medical and surgical wards may improve patient experience and mitigate resource utilization. Objective: We sought to identify common elements for direct admissions, as well as the pattern of disposition for patients referred to our emergency department (ED). Design: A retrospective qualitative analysis of patients transferred to our pediatric hospital for 12 months was performed. Different physician groups were evaluated for use of direct admissions or evaluation in the ED. Patients referred to the ED were additionally tracked to evaluate their eventual disposition. Results: A total of 3982 transfers occurred during the 12-month analysis period. Of those, 3463 resulted in admission, accounting for 32.55% of all admissions. Transfers accepted by nonsurgical services accounted for 82% of the transfers, whereas 18% were facilitated by one of the surgical services. Direct admissions accounted for 1707 (44.8%) of all referrals and were used more often by nonsurgical services. Of patients referred to the ED (2101 or 55.2% of all referrals), most patients were admitted and 343 (16% of those referred to the ED) were discharged home. Conclusions: The direct admission process helped avoid ED assessments for some patients; however, some patients referred to the ED were able to be evaluated, treated, and discharged. Consistent triage of the patients being transferred as direct admissions may improve ED throughput and potentially improve the patient's experience, reduce redundant services, and expedite care

Comparison of Antibiotic Dosing Before and After Implementation of an Electronic Order Set

Background: To maximize resources, the antimicrobial stewardship program at a pediatric tertiary care hospital made pediatric dosing specific guidance within the electronic health record available to all hospitals within the health system. Objective: The objective of this study was to compare the appropriateness of antibiotic dosing before and after the implementation of an electronic intravenous (IV) antibiotic order set. Methods: This was a retrospective cohort study evaluating orders from patients younger than 18 years who received cefepime, piperacillin-tazobactam, tobramycin, or gentamicin at 12 health-system hospitals. Antibiotic dosing regimens and order set use were evaluated in patients who received the specified antibiotics during the 6-month time frame prior to and following electronic order set availability at each hospital. Results: In the before and after implementation periods, 360 and 387 total antibiotic orders were included, respectively. Most orders were gentamicin (55.8% in the before implementation period and 54.5% in the after implementation period) followed by piperacillin-tazobactam (22.5% in the before period and 22.2% in the after period). Overall, 663 orders were classified as appropriate (88.8%). Appropriateness was similar in the before or after implementation periods (87.8 vs. 89.7%, p = 0.415). There was a significant difference in appropriateness if a blank order versus the electronic IV antibiotic order set was used (82.8 vs. 90.5%; p = 0.024). Conclusion: No difference in antibiotic appropriateness overall was found in the before and after implementation periods. However, when specifically compared with the appropriateness of dosing when blank order forms were used, dosing was more appropriate when electronic antibiotic order sets were used

Metamorphism of the Sierra de Maz and implications for the tectonic evolution of the MARA terrane

The Mesoproterozoic MARA terrane of western South America is a composite igneous-metamorphic complex that is important for Paleozoic paleogeographic reconstructions and the relative positions of Laurentia and Gondwana. The magmatic and detrital records of the MARA terrane are consistent with a Laurentian origin; however, the metamorphic and deformation records lack sufficient detail to constrain the correlation of units within the MARA terrane and the timing and mechanisms of accretion to the Gondwana margin. Combined regional mapping, metamorphic petrology, and garnet and monazite geochronology from the Sierra de Maz of northwest Argentina suggest that the region preserves four distinct litho-tectonic units of varying age and metamorphic conditions that are separated by middle- to lower-crustal ductile shear zones. The Zaino and Maz Complexes preserve Barrovian metamorphism and ages that are distinct from other units within the region. The Zaino and Maz Complexes both record metamorphism ca. 430–410 Ma and show no evidence of the regional Famatinian orogeny (ca. 490–455 Ma). In addition, the Maz Complex records an earlier granulite facies event at ca. 1.2 Ga. The Taco and Ramaditas Complexes, in contrast, experienced medium- and low-pressure upper amphibolite to granulite facies metamorphism, respectively, between ca. 470–460 Ma and were later deformed at ca. 440–420 Ma. The Maz shear zone that bounds the Zaino and Maz Complexes records sinistral oblique to sinistral deformation between ca. 430–410 Ma. The data suggest that at least some units in the MARA terrane were accreted by translation, and the Gondwana margin of northwest Argentina transitioned from a dominantly convergent margin to a highly oblique margin in the Silurian

Characteristics of the National Applicant Pool for Clinical Informatics Fellowships (2016-2017)

We conducted a national study to assess the numbers and diversity of applicants for 2016 and 2017 clinical informatics fellowship positions. In each year, we collected data on the number of applications that programs received from candidates who were ultimately successful vs. unsuccessful. In 2017, we also conducted an anonymous applicant survey. Successful candidates applied to an average of 4.2 and 5.5 programs for 2016 and 2017, respectively. In the survey, unsuccessful candidates reported applying to fewer programs. Assuming unsuccessful candidates submitted between 2-5 applications each, the total applicant pool numbered 42-69 for 2016 (competing for 24 positions) and 52-85 for 2017 (competing for 30 positions). Among survey respondents (n=33), 24% were female, 1 was black and none were Hispanic. We conclude that greater efforts are needed to enhance interest in clinical informatics among medical students and residents, particularly among women and members of underrepresented minority groups

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Evaluating the Effects of SARS-CoV-2 Spike Mutation D614G on Transmissibility and Pathogenicity.

Global dispersal and increasing frequency of the SARS-CoV-2 spike protein variant D614G are suggestive of a selective advantage but may also be due to a random founder effect. We investigate the hypothesis for positive selection of spike D614G in the United Kingdom using more than 25,000 whole genome SARS-CoV-2 sequences. Despite the availability of a large dataset, well represented by both spike 614 variants, not all approaches showed a conclusive signal of positive selection. Population genetic analysis indicates that 614G increases in frequency relative to 614D in a manner consistent with a selective advantage. We do not find any indication that patients infected with the spike 614G variant have higher COVID-19 mortality or clinical severity, but 614G is associated with higher viral load and younger age of patients. Significant differences in growth and size of 614G phylogenetic clusters indicate a need for continued study of this variant