Baseline Period Research Articles

#1817 Decrease in hospital-acquired blood stream infection by using automated sensor technology to improve and keep a high level of hand hygiene compliance

Abstract Background and Aims Hospital-acquired infection (HAIs) is a problem for 6-8% of hospitalized patients. HAIs has personal costs, prolongs the hospital stay, increasing the risk of morbidity, mortality, time and staff consuming. Hand hygiene (HH) is essential for preventing infections. World Health Organization (WHO) recommends hand hygiene compliance (HHC) as a key performance indicator. Manual observations of HHC are time consuming and may affect compliance by the physical presence of the observers (Hawthorne effect). There is a need to identify the most effective long-term intervention to improve HHC and reduce HAI. The Danish Ministry of Health have chosen blood stream infections (HA-BSI) as a national indicator for the overall risk of HAIs expecting an incidence of no more than 8 cases per 10,000 patient days. The aim of the present study was to examine the use of an automated sensor technology to improve HHC and prevent HAIs in an inpatient department for nephrology and intern medicine. Nephrology patients have a high number of invasive catheters, which may increases the risk of HAI. Method The study comprised a 2 year cohort with no specific HHC interventions (July 2018-June 2020), a baseline period (February 2020-June 2020) to investigate HHC level by an electronic hand hygiene measuring system (EHHMS) without ongoing HHC interventions followed by a 3 year cohort period (July 2020-June 2023) with various EHHMS-based feedback interventions to staff. Intervention consisted primarily of group feedback and later individual feedback. All caregivers and doctors carried an anonymous Sani ID tag (Sani Nudge, DK) fixed to their nametag throughout the study period. EHHMS-based Sani Sensors were located in designated locations in the clinical department with the purpose of continuously capturing the caregiver patient contact including staff use of liquid alcohol based hand rub (ABHR). In Denmark, the national hygiene guidelines also require that ABHR follow hand wash. Local hygiene mentors regularly presented anonymous group data on boards and in letters to the staff. Soon after there was a demand on individual data, which was then added by individual results forwarded in a personal email every week. HA-BSI was defined as the presence of a pathogen in the blood and the prescription of an appropriate concomitant antimicrobial treatment and classified as hospital-acquired if the patient has been hospitalized for >48 hours. Data were obtained from various electronic health care systems in the hospital. Results We collected HHC data by monitoring 203 caregivers and 50 doctors for a period of 40 months. Caregivers HHC improved after implementation of an electronic hand hygiene measuring system from baseline to group feedback and finally individual feedback (39% vs 50% vs 71%). For doctors, the improvement from baseline to group feedback and finally individual feedback was 30% vs. 32% vs 52%. The overall improvement curve reached a stable plateau after 20 months. An incidence rate of 14 HA-BSI cases per 10,000 patient days during a previous two years control period (95% CI 8.8-21.2) was during the intervention period markedly reduced to 5 HA-BSI cases per 10,000 patient days (95% CI 2.3-9.0). This difference was statistically significant, P = 0.004. Conclusion The use and feedback of the electronic hand hygiene monitoring system improved successfully hand hygiene compliance in the groups of both caregivers, doctors, and furthermore reduced the rate of HA-BSI significantly. We observed a significant stepwise increase in compliance after group feedback data and later after reporting individual data. There continue to be a need to find effective long-term interventions to improve and keep a high level of hand hygiene compliance and a sustained reduction in hospital-acquired bloodstream infection.

Climate variability impacts on runoff projection in the 21st century based on the applicability assessment of multiple GCMs: A case study of the Lushi Basin, China

In this study, we initiatively employed the improved Secure Hash Algorithm (SHA) to evaluate and compare the competencies of multiple Coupled Model Intercomparison Project Phase Six (CMIP6) General Circulation Models (GCMs). The selected GCM outputs were bias-corrected by the non-parametric quantile mapping (QM) method. The calibrated and validated data were then used to run the XAJ (Xin’anjiang) model to assess long-term climate variation impacts on runoff under four Shared Socioeconomic Pathways (SSP1-2.6, SSP2-4.5, SSP3-7.0, and SSP5-8.5), where the results were compared with the baseline period (1976–2000). Overall, the CNRM-CM6-1-HR, FIO-ESM-2–0, INM-CM5-0 and NorESM2-MM models reconstructed better spatio-temporal evolutionary trends related to historical precipitation and evaporation, and were applied as selected GCMs for reliable runoff projection applications. The intensification amplitudes of precipitation and evaporation produced by selected GCMs gradually spread from SSP1-2.6 to SSP5-8.5 throughout the 21st century. Compared to the baseline period (257 m3/s), the extreme streamflow during the wet periods is likely to increase for SSP5-8.5 (288 ∼ 298 m3/s), SSP3-7.0 (276 ∼ 294 m3/s), and SSP2-4.5 (222 ∼ 280 m3/s), whereas SSP1-2.6 decreases to varying degrees (178 ∼ 255 m3/s). Meanwhile, during the dry periods, the extreme streamflow is projected to decrease by 28 ∼ 73 m3/s (SSP5-8.5), 32 ∼ 38 m3/s (SSP3-7.0), 8 ∼ 31 m3/s (SSP2-4.5), and 5 ∼ 33 m3/s (SSP1-2.6) from historical levels (62 m3/s). The overwhelming majority of increasing trends in the wet periods and vastly decreasing trends in the dry seasons indicate that the basin will face some floods and water shortage risks in the mid to late 21st century. The findings broaden the efficacious applications of SHA in the performance selection of GCMs and QM method in bias correction. The conclusions provide a reference for flood and drought mitigation planning and water resources policymaking in the Yellow River Basin.

Healthcare Resource Utilization, Costs, Clinical Events, and Treatment Patterns in Extreme High-Risk Patients for Cardiovascular Events Undergoing Lipoprotein Apheresis: A German Claims Data Analysis

Abstract Aim Insights into treatment patterns, clinical and economic burden of patients undergoing Lipoprotein apheresis (LA). 3 cohorts were characterized: newly treated [Cohort A], experienced [B], matched cohort [C, high CV risk without LA]. Method Clinical burden was assessed by cardiovascular-related hospitalizations and procedures. Economic and clinical outcomes were described over a 12-month baseline period up to 3 years after LA initiation. Results Absolute LA cases decreased from 1.7 to 1.1 per 100,000 patients. In Cohort A, rate of major cardiovascular hospitalizations decreased, while annual healthcare expenditure increased. Cohort B had significantly higher costs than C. Conclusion LA may be associated with a reduced frequency of myocardial infarction-related hospitalizations. However, it is expensive. Alternatives are needed to reduce its high economic burden.

Racial differences in baroreflex function: Implications for the cardiovascular conundrum

Study objectiveAfrican Americans (AAs) show early signs of vascular dysfunction paired with elevated blood pressure (BP) and total peripheral resistance (TPR), which is thought to underlie their increased rates of cardiovascular health complications relative to European Americans (EAs). AAs paradoxically have higher cardiac vagal tone, indexed by heart rate variability (HRV), which is cardio-protective. This paradox has been termed the Cardiovascular Conundrum. The physiological mechanism underlying this phenomenon is not well understood. We examined race differences in baroreflex function, which might be an important mechanism underlying the Cardiovascular Conundrum. DesignParticipants completed a 5-minute baseline period where resting cardiac metrics were assessed. SettingLaboratory. Participants130 college-aged individuals (54 women, 57 AAs). Main outcome measuresBaroreflex function was indexed as baroreflex sensitivity (BRS; the magnitude of changes in cardiovascular activity in accordance with BP changes) and effectiveness (BEI; the ratio of BP changes that elicit changes in cardiovascular activity) in the cardiac, vascular, and myocardial limbs. Results and conclusionsResults showed AAs to have higher HRV and cardiac BRS in comparison to EAs, suggesting the baroreflex is more sensitive to correcting the heart period for changes in BP among AAs compared to EAs. However, AAs showed lower vascular BEI relative to EAs, suggesting less effective control of TPR. In sum, lower BEI in the vascular branch might be an important mechanism underlying the Cardiovascular Conundrum (i.e., higher HRV and BP) and by extension, health disparities in cardiovascular diseases between AAs and EAs.

Budyko-based past and future disaggregation of climate and catchment effects on streamflow changes

ABSTRACT Budyko-based approaches are widely used to separate climate and catchment effects on streamflow changes. Considering the potential changes in streamflow, such separation is essential for future water resources management. In this study, we propose a method that allows for continuous disaggregation of climate and catchment impacts from the past to the future. We utilize a generalized linear model to represent catchment parameters based on climate and catchment features. Subsequently, we determine the future positions of the catchment in the Budyko-state space. This framework is applied to four Model Parameter Estimation Experiment (MOPEX) catchments with varying aridity indices in the USA. The results indicate that, in the recent historical period (1971–2011), climate change has contributed to increased streamflow in three catchments compared to the baseline (1948–1970) period. However, future projections indicate a mixed pattern of contributions in two of these catchments due to increased potential evapotranspiration, resulting in decreased streamflow.

Personalizing cardiovascular risk prediction for patients with systemic lupus erythematosus

ObjectiveCardiovascular disease (CVD) risk is increased in SLE and underestimated by general population prediction algorithms. We aimed to develop a novel SLE-specific prediction tool, SLECRISK, to provide a more accurate estimate of CVD risk in SLE. MethodsWe studied patients in the Brigham and Women's Hospital SLE cohort. We collected one-year baseline data including the presence of traditional CVD factors and SLE-related features at cohort enrollment. Ten-year follow-up for the first major adverse cardiovascular event (MACE; myocardial infarction (MI), stroke, or cardiac death) began at day +1 following the baseline period (index date). ICD-9/10 codes identified MACE were adjudicated by board-certified cardiologists. Least absolute shrinkage and selection operator regression selected SLE-related variables to add to the American College of Cardiology/American Heart Association (ACC/AHA) Pooled Cohort Risk Equations 10-year risk Cox regression model. Model fit statistics and performance (sensitivity, specificity, positive/negative predictive value, c-statistic) for predicting moderate/high 10-year risk (≥7.5 %) of MACE were assessed and compared to ACC/AHA, Framingham risk score (FRS), and modified FRS (mFRS). Optimism adjustment internal validation was performed using bootstrapping. ResultsWe included 1,243 patients with 90 MACEs (46 MIs, 36 strokes, 19 cardiac deaths) over 8946.5 person-years of follow-up. SLE variables selected for the new prediction algorithm (SLECRISK) were SLE activity (remission/mild vs. moderate/severe), disease duration (years), creatinine (mg/dL), anti-dsDNA, anti-RNP, lupus anticoagulant, anti-Ro positivity, and low C4. The sensitivity for detecting moderate/high-risk (≥7.5 %) of MACE using SLECRISK was 0.74 (95 %CI: 0.65, 0.83), which was better than the sensitivity of the ACC/AHA model (0.38 (95 %CI: 0.28, 0.48)). It also identified 3.4-fold more moderate/high-risk patients than the ACC/AHA. Patients who were moderate/high-risk according to SLECRISK but not ACC/AHA, were more likely to be young women with severe SLE and few other traditional CVD risk factors. Model performance between SLECRISK, FRS, and mFRS were similar. ConclusionThe novel SLECRISK tool is more sensitive than the ACC/AHA for predicting moderate/high 10-year risk for MACE and may be particularly useful in predicting risk for young females with severe SLE. Future external validation studies utilizing cohorts with more severe SLE are needed.

Representative concentration pathways (RCPs) used as a tool to evaluate climate change impact on maize crop production in the Woybo catchment of Ethiopia

ABSTRACT The research was conducted to assess the climate change impact on crop water requirements (CWRs) in the Woybo catchment of southern Ethiopia. The impact of climate change was assessed through climate models under RCP4.5 and RCP8.5 emission scenarios for the 2050s compared to 1971–2005. During the 2050s, the annual mean minimum temperature increased by 1.9–2.3 °C, while the maximum temperature over the catchment increased by 1.4–2.0 °C. The projected rainfall is expected to increase in autumn, summer, and annually by 3.7–16.8 and 8.7–12.2% in the 2050s under RCP4.5 and 8.5, respectively. But it is likely to decrease in winter and spring by 1.5–10.2% and 8.7–2.8%, respectively. The average annual potential evapotranspiration will rise by 0.1–6.8%. Under both RCPs, CWRs may increase from 6.2 to 17.2% during the growing season, while irrigation water requirements (IWRs) may rise from 4.6 to 16.4%. Future period projection results show that potential evapotranspiration and IWRs will increase for maize crops compared to the baseline period. The study will help water managers, users, and agricultural developers in preparing new water-saving strategies and achieving agricultural sustainability.

Sex Differences in Time to Initiate Nonsteroidal Anti-Inflammatory Drugs or Biologic Disease-Modifying Antirheumatic Drugs Among Patients With Axial Spondyloarthritis.

We evaluated sex differences in time to initiation of receiving nonsteroidal anti-inflammatory drugs (NSAIDs) or biologic disease-modifying antirheumatic drugs (bDMARDs) among patients with axial spondyloarthritis (axSpA). Using the 2013 to 2018 IBM MarketScan Database, we identified 174,632 patients with axSpA aged ≥18 years. We evaluated the time between axSpA diagnosis and the first prescription NSAID dispensing (among those with no baseline NSAIDs reception) or bDMARDs infusion/procedure claim (among those who were dispensed two or more different prescription NSAIDs in the baseline period). Adjusted hazard ratios (aHRs) for time to initiation of patients receiving NSAIDs or bDMARDs were computed using survival analyses. Cox proportional hazard models estimated associations between sex and predictors of treatment initiation. Average age at diagnosis was 48.2 years, 65.7% were female, and 37.8% were dispensed one or more NSAIDs before axSpA diagnosis. Of those who did not receive two or more different prescription NSAIDs before diagnosis, NSAID reception was initiated earlier in female patients than in male patients (NSAID reception initiators: female patients (32.9%), male patients (29.3%); aHR 1.14, 95% confidence interval [CI] 1.11-1.16). Among those who received two or more different prescription NSAIDs in the baseline period, 4.2% received a bDMARD, whereas 77.9% continued receiving NSAIDs after diagnosis. Time to bDMARD reception initiation was longer for female patients than for male patients (aHR 0.61, 95% CI 0.52-0.72), but bDMARDs were received sooner among those who received NSAIDs in the baseline period. Prescription NSAID reception was more common than initiation of receiving bDMARDs among patients newly diagnosed with axSpA. Female patients appeared more likely to continue receiving NSAIDs after diagnosis, and the time to initiation of receiving bDMARDs was longer for female patients than for male patients.

Exploring the Impact of Climate Change on Water Resources for Vegetation Covers in Extremadura (Spain)

Mediterranean areas will likely undergo climate shifts in the near future that modify the water resources for vegetation. However, in some regions of southwestern Spain, such as Extremadura, the impact of different future scenarios on the water resources for vegetation has not been studied extensively. This study focused on the quantification and spatial distribution of water resources for vegetation covers in Extremadura and analyzed the impact of future climate change scenarios on those water resources. For this, five downscaled global climate models from Coupled Model Intercomparison Project phase 6 (CMIP6) were used in four future periods (from 2021 to 2100) following two Shared Socioeconomic Pathways (SSP-2.45 and SSP-5.85). These projections were compared with a historical baseline period (1970–2000) to obtain the variation of water resources. The results showed decreases in the water resources for all the scenarios and periods analyzed compared to those observed in the historical baseline period. The smallest decreases were noted over 2041–2060 for SSP2-4.5, with almost 74% of the region decreasing between 15 and 18% (with an average of 16.4%). The greatest decreases were over 2081–2100 for SSP5-8.5, in which 90% of the region displayed water resource declines of greater than 50%. In this last situation, the three more widespread vegetation covers (agrosilvopastoral systems of dehesas, grasslands, and crops) underwent similar declines of around 55% of their water resources (from ≈203 to ≈93 mm), while the fourth widely spread vegetation cover, forests, declined by 49% (from ≈261 to ≈133 mm). If any of these future projections occur, the decline in water resources could modify the forest composition and structure of these water-dependent ecosystems, compromising their maintenance and ecological, cultural, and economic functions.

SABINA + Hong Kong: a territory wide study of prescribing trends and outcomes associated with the use of short-acting β2 agonists in the Chinese population

BackgroundExcessive use of short-acting β2 agonists (SABA) in patients with asthma continues to be a notable concern due to its link to higher mortality rates. Global relevance of SABA overuse in asthma management cannot be understated, it poses significant health risk to patients with asthma and imposes burden on healthcare systems. This study, as part of global SABINA progamme, aimed to describe the prescribing patterns and clinical outcomes associated with SABA use in the Chinese population.MethodsRetrospective cohort study was conducted using anonymized electronic healthcare records of Clinical Data Analysis and Reporting System (CDARS) from Hong Kong Hospital Authority (HA). Patients newly diagnosed with asthma between 2011 and 2018 and aged ≥12 years were included, stratified by SABA use (≤2, 3–6, 7–10, or ≥11 canisters/year) during one-year baseline period since asthma diagnosis date. Patients were followed up from one-year post-index until earliest censoring of events: outcome occurrence and end of study period (31 December 2020). Cox proportional regression and negative binomial regression were used to estimate the mortality risk and frequency of hospital admissions associated with SABA use respectively, after adjusting for age, sex, Charlson Comorbidity Index (CCI), and inhaled corticosteroid (ICS) dose. Outcomes include all-cause, asthma-related, and respiratory-related mortality, frequency of hospital admissions for any cause, and frequency of hospital admissions due to asthma.Results17,782 patients with asthma (mean age 46.7 years, 40.8% male) were included and 59.1% of patients were overusing SABA (≥ 3 canisters per year). Each patient was prescribed a median of 5.61 SABA canisters/year. SABA overuse during baseline period was associated with higher all-cause mortality risk compared to patients with ≤2 canisters/year. Association was dose-dependent, highest risk in those used ≥11 canisters/year (adjusted hazard ratio: 1.42, 95% CI: 1.13, 1.79) and 3–6 canisters/year (adjusted hazard ratio: 1.22, 95% CI: 1.00, 1.50). Higher SABA prescription volume associated with increased frequency of hospital admissions with greatest risk observed in 7–10 canisters/year subgroup (adjusted rate ratio: 4.81, 95% CI: 3.66, 6.37).ConclusionsSABA overuse is prevalent and is associated with increased all-cause mortality risk and frequency of hospital admissions among the patients with asthma in Hong Kong.

Compound successive dry-hot and wet extremes in China with global warming and urbanization

Global warming has accelerated the interregional hydrological cycle, resulting in a significant increase in the frequency and intensity of extreme events worldwide. These events often involve a combination of spatial and temporal factors, giving rise to compound events. Among them are rapid transitions from dry and hot conditions to wet (DHW) events, which can have more severe impacts on human societies and ecosystems than individual extreme events. Urbanization not only heightens the likelihood of disasters but also exacerbates the exposure of affected populations. However, there has been insufficient attention given to understanding the connections between these successive compound events and the heightened risks posed by the increasing urbanization. In this study, we used bias-corrected daily precipitation and maximum temperature data simulated by the Coupled Model Intercomparison Project Phase 6 (CMIP6) model, along with historical and future daily runoff data simulated by the Variable Infiltration Capacity (VIC) model. We systematically investigated the spatiotemporal changes (i.e., frequency, duration, intensity, and compound probability) in DHW events in China during the upper historical period (1979–2014) and under two medium and high emission scenarios (2015–2100) − Shared Socioeconomic Pathways (SSP245 and SSP585). Furthermore, we examined how extreme runoff responds to variations in maximum temperature and daily precipitation during DHW events. We also evaluated the potential population and urban exposure to DHW events using dynamic future population and urban expansion data to assess the potential risks. Our results indicate that the multi-model ensemble predicts varying spatial patterns of future DHW events under SSP245 and SSP585 scenarios. The frequency and duration of these events are expected to decrease by approximately 20–25% in the Northwest region under both scenarios. At the same time, the middle and lower plains of the Yangtze and Yellow River Basins experience increased occurrence, broader geographical impact, and higher DHW event intensity alongside urban expansion and population growth in these regions. Specifically, event intensity is anticipated to increase by a factor of approximately 7–11. Temporally, we expect short-duration, high-intensity DHW events to occur in the Yangtze and Yellow River basins around 2023, 2038, and 2058, respectively. The primary driver for the future rise in population exposure to DHW events is the expected increase in event frequency in the middle and lower plains of the Yangtze and Yellow River basins, concurrent with population growth in these regions. Under the medium emission scenario, the total exposed population to DHW events in China is predicted to be 1.61 times higher than the historical baseline. In contrast, the high-emission scenario estimates a total population of 2.41 times higher than the historical baseline period. Most of the DHW events occurred in regions that exhibit a positive dependence between high temperature and high runoff events, serving as the primary driver of DHW events. Urbanization has a positive impact on DHW events, with the effect under high emissions being approximately 30% higher than during the historical base period. Additionally, it is indicated that future DHW events will exhibit higher sensitivity to global warming, with intensity projected to increase approximately fourfold and the exposed population to rise by about 1.5 times for every 1 °C of global warming. This research enhances our understanding of forecasting future compound hydrometeorological extreme events under different scenarios and provides insight into the role of climate change and urbanization in shaping these events in China.

Changing Your Tune: Lessons for Using Music to Encourage Physical Activity

Our research investigated whether music can communicate physical activity levels in daily life. Past studies have shown that simple musical tunes can provide wellness information, but no study has examined whether musical feedback can affect daily behavior or lead to healthier habits. We conducted a within-subject study with 62 participants over a period of 76 days, providing either musical or text-based feedback on their daily physical activity. The music was built and personalized based on participants' step counts and baseline wellness perceptions. Results showed that participants were marginally more active during the music feedback compared to their baseline period, and significantly more active compared to the text-based feedback (p = 0.000). We also find that the participant's average activity may influence the musical features they find most inspiration within a song. Finally, context influenced how musical feedback was interpreted, and specific musical features correlated with higher activity levels regardless of baseline perceptions. We discuss lessons learned for designing music-based feedback systems for health communication.

Breaking the spell: Changes in the behavior of two zoo-kept tigers (Panthera tigris) after exposure to a distinct feast-and-fast feeding regime.

The behavior of zoo carnivores has received intense attention due to their propensity for locomotor stereotypies. We observed two adult male tiger (Panthera tigris) siblings kept together for the duration of 104 days by round-the-clock video observation. The period consisted of three baseline periods with the zoo's regular feeding regime of five feeding days per week interrupted by two individual fasting days, with feeding occurring in the evening (B1-B3 of 14 days each). These periods were interrupted by two intervention periods (I1: randomized feeding times, 28 days; I2: gorge-feeding with three 10-day fasting periods, 34 days). As expected, day and night-time behavior was different, with the majority of sleep occurring at night. Pacing, which was mainly considered anticipatory, significantly decreased from 88 ± 132 min/day during B1 to 20 ± 33 min/day during B3. Pacing did not increase during the fasting days of I2. Over the course of whole study, lying time decreased and nonpacing locomotion increased. A major difference was observed between gorge-feeding and the subsequent first fasting days: during gorge-feeding, tigers spent a large part of the day feeding and locomoting (and less sleeping); on the subsequent day, they locomoted about 4.5 h less and slept about 4.3 h more. We suggest that interrupting routines by fasting periods of several days may be effective for reducing regular anticipatory behavior and creates an across-day structure that may correspond to the evolved psychological disposition of large carnivores.

Meta-cognitive Therapy in Obsessive Compulsive Disorder: A Case Report

Psychotherapeutic developments in the management of anxiety disorders are evolving, with notable evidence in obsessive compulsive disorder (OCD). Third-wave therapies significantly contribute to the reduction in psychopathological symptoms and, thus, provide a positive turning point in the socio-occupational spectrum of the patient. One such third-wave approach is meta-cognitive therapy (MCT), which addresses cognitive attention syndrome (CAS) and directly prohibits ritualistic behavior, thereby decreasing the burden of symptoms. In India, it seems there is a dearth of literature exploring the effectiveness of MCT. The present case report provides a detailed insight into the psychotherapeutic treatment using MCT, in which 10 sessions were provided to an OCD patient along with pharmacotherapy. The treatment shows a noteworthy improvement in thought fusion, obsessional beliefs, meta-cognitive beliefs, and psychopathology. The symptoms gradually waned during the three- and six-month follow-up baseline period. Therefore, the case report demonstrates the effectiveness of combined medication and MCT in treating OCD. Additionally, it shows the potency of MCT in prolonged improvements in cognitive flexibility and inflated feelings of responsibility and perfection.

Treatment Patterns, Acute Healthcare Resource Use, and Costs of Patients with Treatment-Resistant Depression Completing Induction Phase of Esketamine in the United States.

This study aimed to understand treatment patterns, acute healthcare use, and cost patterns among adults with treatment-resistant depression (TRD) who completed induction treatment with esketamine nasal spray in the United States (US). Per label, induction is defined as administration twice a week for 4 weeks, after which maintenance is started on a weekly basis for 4 weeks, and thereafter, patients are treated weekly or bimonthly. Adults with one or more esketamine claim (index date) on or after March 5, 2019 were selected from Optum's de-identified Clinformatics® Data Mart Database (January 2016-June 2022). Before the index date, patients had evidence of TRD and ≥12 months of continuous insurance eligibility (baseline period). Patients with eight or more esketamine treatment sessions were included in the main cohort. A subgroup included patients with one or more baseline mental health (MH)-related inpatient (IP) admission or emergency department (ED) visit (i.e., prior acute healthcare users). Treatment patterns were described during the follow-up period (index date until earliest of end of insurance eligibility or data); acute healthcare (i.e., IP and ED) resource use and costs (2021 US dollars) were reported during the baseline and follow-up periods. Of the 322 patients in the main cohort, 111 comprised the subgroup of prior acute healthcare users. During the follow-up period, mean time from index date to eighth esketamine session was 73.2days in the main cohort and 78.8days in the subgroup (per label, 28days). Further, 75.2% of the main cohort and 73.9% of the subgroup completed four or more esketamine maintenance sessions following induction. In the main cohort, mean all-cause acute healthcare costs per patient per month (PPPM) decreased from baseline ($837) to follow-up ($770). Similar reductions were observed for mean MH-related acute healthcare costs PPPM (baseline $648, follow-up $577). In the subgroup, mean all-cause acute healthcare costs PPPM also decreased (baseline $2323, follow-up $1423), driven by mean MH-related acute healthcare costs PPPM (baseline $1880, follow-up $1139). Mean all-cause acute healthcare use per ten patients per month remained largely stable from baseline to follow-up in the main cohort (IP days: baseline 2.24, follow-up 2.13; ED visits: baseline 1.33, follow-up 1.45) and decreased in the subgroup (IP days: baseline 6.38, follow-up 4.56; ED visits: baseline 2.58, follow-up 2.41). Trends in mean MH-related acute healthcare use were similar. Patients generally required more time than label recommendation to complete esketamine induction treatment, and most went on to have 12 or more esketamine sessions. Completion of induction treatment correlated with reductions in mean all-cause and MH-related acute healthcare costs. Larger reductions were seen in the subgroup of prior acute healthcare users.

Non-Invasive Monitoring of Microvascular Oxygenation and Reactive Hyperemia using Hybrid, Near-Infrared Diffuse Optical Spectroscopy for Critical Care.

The detection of levels of impairment in microvascular oxygen consumption and reactive hyperemia is vital in critical care. However, there are no practical means for a robust and quantitative evaluation. This paper describes a protocol to evaluate these impairments using a hybrid near-infrared diffuse optical device. The device contains modules for near-infrared time-resolved and diffuse correlation spectroscopies and pulse-oximetry. These modules allow the non-invasive, continuous, and real-time measurement of the absolute, microvascular blood/tissue oxygen saturation (StO2) and the blood flow index (BFI) along with the peripheral arterial oxygen saturation (SpO2). This device uses an integrated, computer-controlled tourniquet system to execute a standardized protocol with optical data acquisition from the brachioradialis muscle. The standardized vascular occlusion test (VOT) takes care of the variations in the occlusion duration and pressure reported in the literature, while the automation minimizes inter-operator differences. The protocol we describe focuses on a 3-min occlusion period but the details described in this paper can readily be adapted to other durations and cuff pressures, as well as other muscles. The inclusion of an extended baseline and post-occlusion recovery period measurement allows the quantification of the baseline values for all the parameters and the blood/tissue deoxygenation rate that corresponds to the metabolic rate of oxygen consumption. Once the cuff is released, we characterize the tissue reoxygenation rate, magnitude, and duration of the hyperemic response in BFI and StO2. These latter parameters correspond to the quantification of the reactive hyperemia, which provides information about the endothelial function. Furthermore, the above-mentioned measurements of the absolute concentration of oxygenated and deoxygenated hemoglobin, BFI, the derived metabolic rate of oxygen consumption, StO2, and SpO2 provide a yet-to-be-explored rich data set that can exhibit disease severity, personalized therapeutics, and management interventions.

Real-World Treatment Patterns Among Patients with Type 2 Diabetes Mellitus Initiating Treatment with Oral Semaglutide.

The treatment landscape for type 2 diabetes mellitus (T2DM) is complex and constantly evolving, and real-world evidence of prescribing patterns is limited. The objectives of this study were to characterize lines of therapy (LOTs), calculate the length of time spent on each LOT, and identify the reasons for the LOT end among patients who initiated oral semaglutide for T2DM. This retrospective, claims-based study included commercial and Medicare Advantage adults with T2DM. Data from November 1, 2019, and June 30, 2020, were obtained from Optum Research Database. Patients with ≥ 1 claim for oral semaglutide and continuous health plan enrollment for ≥ 12months prior to (baseline period) and ≥ 6months following (follow-up period) the date of the first oral semaglutide claim were included. LOT 1 began on the date of the first oral semaglutide claim. The start date of any subsequent LOTs was the date of the first claim for an additional non-insulin anti-diabetic drug class or a reduction in drug class with use of commitment medications. The LOT ended at the first instance of medication class discontinuation, change in regimen or end of follow-up. Of the 1937 patients who initiated oral semaglutide, 950 (49.0%) remained on their initial regimen over the 6-month follow-up period, 844 (43.6%) had at least one subsequent LOT, and 89 (4.6%) had at least two subsequent LOTs. Among patients with more than one LOT, approximately 20%-25% used oral semaglutide as monotherapy or combination therapy during LOTs 2 and 3. Metformin was frequently used during treatment across all LOTs. This study provides insight for physicians and payers into the real-world prescribing practices within the first 6months following oral semaglutide initiation and fills the gap in understanding the frequency of regimen changes in the constantly evolving and complex environment of T2DM care.

Assessment of hydrological baseline condition and its alteration in Athabasca River Basin, Canada

Study regionAthabasca River Basin (ARB), Canada. Study focusThis study aimed to characterize the flow regime of the ARB, a basin with diverse hydroclimatic and geological characteristics. Forty-two different flow indicators from the Indicators of Hydrological Alteration (IHA) and Cold regions Hydrological Indicators of Change (CHIC) were employed. The natural range of these indicators was established for the baseline period (1961–1990), and subsequent alterations during the recent period (1991–2020) were systematically examined. Principal Component Analysis (PCA) was applied to identify pivotal indicators shaping the basin's flow regime. In addition, trends of key indicators were examined at eight distinct locations within the basin. New hydrological insights for the study regionThe findings indicate spatiotemporal variation between the basin's upper and lower parts. The upstream region exhibited an earlier peak flow (9 days), an earlier ice break-up (17 days), and a shorter ice cover duration (22 days) compared to the downstream region. Increased winter and spring flow have led to an augmentation of annual flow by 3.8 % in the upper region. In contrast, downstream flow experienced a decline throughout the year (11.38 %), which was found to be statistically significant at a rate of 3.24 m3/s/year. Alteration analysis revealed a shift toward the 'low category' (below their defined baseline range) for most indicators in the recent period, underscoring a transition towards a diminishing flow regime, with an overall alteration ranging at low to moderate levels (19–38 %). Late summer flow reduction (8–25 %) can have critical implications, given the rising water demand in the basin. The study identified eleven key indicators encapsulating the basin's flow regime variability range. It was found that ice cover, its break-up, and spring freshet significantly influence the flow regime of the basin. The findings from this study will assist decision-makers in making more informed decisions for the holistic management of water resources in the basin.

Increasing the Use of Enteral Antibiotics in Hospitalized Children With Uncomplicated Infections.

Route of administration is an important component of antimicrobial stewardship. Early transition from intravenous to enteral antibiotics in hospitalized children is associated with fewer catheter-related adverse events, as well as decreased costs and length of stay. Our aim was to increase the percentage of enteral antibiotic doses for hospital medicine patients with uncomplicated common bacterial infections (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection, neck infection) from 50% to 80% in 6 months. We formed a multidisciplinary team to evaluate key drivers and design plan-do-study-act cycles. Interventions included provider education, structured discussion at existing team huddles, and pocket-sized printed information. Our primary measure was the percentage of antibiotic doses given enterally to patients receiving other enteral medications. Secondary measures included antibiotic cost, number of peripheral intravenous catheters, length of stay, and 7-day readmission. We used statistical process control charts to track our measures. Over a 6-month baseline period and 12 months of improvement work, we observed 3183 antibiotic doses (888 in the baseline period, 2295 doses during improvement work). We observed an increase in the percentage of antibiotic doses given enterally per week for eligible patients from 50% to 67%. We observed decreased antibiotic costs and fewer peripheral intravenous catheters per encounter after the interventions. There was no change in length of stay or readmissions. We observed increased enteral antibiotic doses for children hospitalized with common bacterial infections. Interventions targeting culture change and communication were associated with sustained improvement.

Assessing Climate-Change-Driven Impacts on Water Scarcity: A Case Study of Low-Flow Dynamics in the Lower Kalu River Basin, Sri Lanka

The adverse impacts of climate change are becoming more frequent and severe worldwide, and Sri Lanka has been identified as one of the most severely affected countries. Hence, it is vital to understand the plausible climate-change-driven impacts on water resources to ensure water security and socio-economic well-being. This study presents novel assessments on low-flow dynamics along the lower Kalu River Basin, Sri Lanka, and water availability during the dry spells of the 2030–2060 period. Bias-corrected daily precipitation projections of a high resolution (25 km × 25 km) NCC-NORESM1-M regional climate model is used here to force a calibrated HEC-HMS hydrological model to project catchment discharge during the future period considered under the two end-member Representative Concentration Pathways (i.e., RCP 2.6 and RCP 8.5). Our results show that the study area (i.e., Kuda Ganga sub-basin) may become warmer (in non-monsoonal periods) and wetter (in monsoon season) under both scenarios during the near future (2030–2040) when compared to the baseline period (1976–2005) considered. Consequently, the streamflow may reduce, making it the decade with the largest water deficit within the time horizon. The subsequent deficit volume assessment for the 2031–2040 period shows a probable water shortage (~5 million m3) under the RCP 2.6 scenario, which may last for ~47 days with an average daily intensity of 105,000 m3. Our results highlight the need of incorporating climate-change-driven impacts in water resources management plans to ensure water security.