Metropolitan Centers Research Articles

Time-to-care metrics in patients with interhospital transfer for mechanical thrombectomy in north-east Germany: Primary telestroke centers in rural areas vs. primary stroke centers in a metropolitan area.

Mechanical thrombectomy (MT) is highly effective in large vessel occlusion (LVO) stroke. In north-east Germany, many rural hospitals do not have continuous neurological expertise onsite and secondary transport to MT capable comprehensive stroke centers (CSC) is necessary. In metropolitan areas, small hospitals often have neurology departments, but cannot perform MT. Thus, interhospital transport to CSCs is also required. Here, we compare time-to-care metrics and outcomes in patients receiving MT after interhospital transfer from primary stroke centers (PCSs) to CSCs in rural vs. metropolitan areas. Patients from ten rural telestroke centers (RTCs) and nine CSCs participated in this study under the quality assurance registry for thrombectomies of the Acute Neurological care in North-east Germany with TeleMedicine (ANNOTeM) telestroke network. For the metropolitan area, we included patients admitted to 13 hospitals without thrombectomy capabilities (metropolitan primary stroke centers, MPSCs) and transferred to two CSCs. We compared groups regarding baseline variables, time-to-care metrics, clinical, and technical outcomes. Between October 2018 and June 2022, 50 patients were transferred from RTCs within the ANNOTeM network and 42 from MPSCs within the Berlin metropolitan area. RTC patients were older (77 vs. 72 yrs, p = 0.05) and had more severe strokes (NIHSS 17 vs. 10 pts., p < 0.01). In patients with intravenous thrombolysis (IVT; 34.0 and 40.5%, respectively), time from arrival at the primary stroke center to start of IVT was longer in RTCs (65 vs. 37 min, p < 0.01). However, RTC patients significantly quicker underwent groin puncture at CSCs (door-to-groin time: 42 vs. 60 min, p < 0.01). Despite longer transport distances from RTCs to CSCs (55 vs. 22 km, p < 0.001), there was no significant difference of times between arrival at the PSC and groin puncture (210 vs. 208 min, p = 0.96). In adjusted analyses, there was no significant difference in clinical and technical outcomes. Despite considerable differences in the setting of stroke treatment in rural and metropolitan areas, overall time-to-care metrics were similar. Targets of process improvement should be door-to-needle times in RTCs, transfer organization, and door-to-groin times in CSCs wherever such process times are above best-practice models.

Are medium-sized cities strong nodes in the settlement system? Demographic trends of Italian provincial capitals from 2000 to the Covid-19 pandemic

Medium-sized cities are an important component of the settlement system and are often described as a joining link between urban and rural areas. However, in recent decades they have been impacted by growing competition from large cities which have tremendous appeal for the post-Fordist economy and for various segments of the population. This paper analyses the demographic trajectories of 99 medium-sized cities in Italy with provincial capital status, from the beginning of the twenty-first century to the outbreak of the COVID-19 pandemic. Over a twenty-year period marked by many difficulties for the Italian economy in an international context, what has the demographic performance of these cities been? The research addresses two areas. On the one hand, it analyses the demographic vitality of the provincial capitals compared to the metropolitan centres; on the other, it follows the redistribution of populations in the provincial capitals’ urban areas, which coincide with the employment areas (Sistemi locali del lavoro). Significant behavioural discontinuities emerge between the decade of 2000-2010 and the following decade, which was characterised by a gradual recovery after the shock of the Great Recession. The picture was changed further by the COVID-19 pandemic. Furthermore, persistent differences between the medium-sized cities of Northern and Southern Italy stand out, but so do new internal divisions within the country, reframing this historical dualism.

SCHOOLS OF ETHNIC MINORITIES IN MOSCOW AND LENINGRAD (1928–1937)

The system of ethnic education in the USSR in the period preceding World War II had already formed in two metropolitan centers. Analysis of data on the number of national schools and the system of teacher training for them was carried out on the basis of data from reference publications of the period under review. The most important changes in the management of national education and cultural institutions throughout the country are considered.

Sport management “a look at the sport managerIn the current professional context”

Today's world moves at breakneck speed in a so-called timeless culture where occupations and professional obligations are becoming increasingly broad and complex. Sports management is no different, requiring sports managers to acquire a diverse set of duties and skills, significantly expanding their competencies. The purpose of this study is to provide third-year sports management undergraduates at the Universidade Autonoma de Lisboa with the opportunity to reflect on the theme "A look at the sports manager in the current professional context" through sustained practices based on a set of variables relating to: the sports manager; organizational management; sports manager skills; and future challenges. According to the sociodemographic analysis, pupils had generalized thinking depending on age, gender, household, geographical closeness to Lisbon's metropolitan center, and nationality. We employed a quantitative, descriptive methodology. When confronted with the study factor "Challenges," which significantly influenced the student’s perception of this issue, the results revealed a generalized opinion among the students under study regarding "A look at the sports manager in the current professional context".

Temporal and Regional Trends in Obstructive Sleep Apnea Using Administrative Health Data in Alberta, Canada.

Rationale: Obstructive sleep apnea (OSA) is a common treatable condition with important health and societal consequences. Objectives: We aimed to assess the annual incidence and prevalence of clinically recognized and geographic clustering of OSA in Alberta, Canada, using administrative health data case definitions. Methods: We used two administrative health databases in Alberta to identify ICD-9 and ICD-10 (International Classification of Diseases, Ninth and 10th Revisions, respectively) diagnostic codes for adults and children at least 2 years old diagnosed with OSA between 2003 and 2020. We defined OSA using an algorithm developed and validated in Alberta: at least three claims or one hospitalization within 2 years. We mapped residential postal codes to 70 subregional health authorities (SRHAs). Crude, age group- and sex-specific incidence and prevalence, and age group- and sex-standardized rates were calculated for Alberta and SRHAs. Spatial scan statistics identified clusters of SRHAs in which OSA cases were higher (hot spots) or lower (cold spots) than expected. Results: Between 2003 and 2020, OSA prevalence increased from 0.14% to 4.59%. The annual incidence of OSA increased after 2013. Incidence and prevalence were higher in older adults and children aged 2-11 years compared with 12-17 years. Cluster analysis revealed regional variation in OSA incidence and prevalence over time with no consistent pattern except for cold spots in one large metropolitan center (Calgary). Conclusions: From 2003 to 2020, the incidence and prevalence of clinically recognized OSA increased but varied by geography. Administrative health data can be used to guide interventions aimed at improving health service delivery and the quality of OSA care.

Don't go breaking apart: Anthropogenic disturbances predict meadow fragmentation of an endangered seagrass

Abstract Although it is well established that human activities are linked to the loss of seagrasses worldwide, the influence of anthropogenic disturbances on the habitat fragmentation of seagrass meadows is less understood. This information is essential to identify how humans are modifying seascapes and what disturbances pose the greatest risk to seagrasses, which is pertinent given the rapid urbanization occurring in coastal areas. This study examined how the habitat fragmentation of an endangered seagrass Posidonia australis varied in relation to several anthropogenic disturbances (i.e. human population, marine infrastructure, terrestrial run‐off and catchment land‐usage) within 10 estuaries across 620 km of coastline in New South Wales, Australia. When comparing between estuaries, the fragmentation of P. australis meadows was significantly greater in estuaries adjacent to highly populated metropolitan centres – generally in the Greater Sydney region. At sites within estuaries, the density of boat moorings was the most important predictor of habitat fragmentation, but there was also evidence of higher fragmentation with increased numbers of jetties and oyster aquaculture leases. These results suggest that the fragmentation of seagrass meadows will become more pervasive as the human population continues to grow and estuarine development increases. Strategies to mitigate anthropogenic disturbances on seagrass meadow fragmentation could include prohibiting the construction of boat moorings and other artificial structures in areas where seagrasses are present or promoting environmentally friendly designs for marine infrastructure. This knowledge will support ongoing management actions attempting to balance coastal development and the conservation of seagrasses.

Worlding Dutch Literary Studies

ABSTRACT Whenever we start worlding Dutch literary studies, we find ourselves in the compartment. Once we move beyond the metropolitan centre(s) of Dutch literature, we encounter the compartments of literatures from or related to Indonesia, the Antilles, South Africa, Suriname, Congo, immigration to the metropolitan centres. This essay discusses ‘worlding’ as a possible method that can undo the compartments while also tackling the racialized logic that underpin them. After a general description of ‘worlding’, the essay discusses three recent publications that deal with the colonial past of the Low Countries: De postkoloniale spiegel, De nieuwe koloniale leeslijst and Zwarte bladzijden. Whereas all include aspects that world the discipline, a distinction can be made between the first two projects that involve a recentring on the nation and leave the compartments intact and the third one that offers a more oppositional strategy of worlding that addresses the racial grammar that subtends the discipline of Dutch literary studies and that invites us to imaginative acts of worldmaking.

Writing the Caribbean in Magazine Time

Writing the Caribbean in Magazine Time

Analysis of Transport and Vehicular Road Crash Cases in Metro Manila from 2016 to 2020

Introduction. Metro Manila, the metropolitan center and seat of the national government, is composed of 16 cities and 1 municipality, and considered as the second-most populous region in the Philippines. Transport is a key sector that is needed for accessibility and economic progress. Yet, the question on safety of the roads of Manila remains as road crashes continue to be reported.Objective. The study aims to determine the trend of road crashes in Metro Manila, and the factors associated with both fatality and injury among three types of road users – the drivers, the passengers, and the pedestrians.Methods. A retrospective analysis of 523,059 road crash data between 2016 to 2020 was done. Using descriptive statistics, the road crash variables analyzed in the study were (1) crash classification according to damage to property, fatal, and non-fatal crash, (2) road user type according to driver, passenger, and pedestrian, (3) vehicle type, (4) junction type, and (5) risky road user behavior. Logistic and multinomial regression models were used to determine whether these variables were significant with road user fatality and injury.Results. The analysis of the MMARAS database (n=523,059) showed an increasing trend of road crashes occurred since 2016 and peaked in 2019, and declined in 2020. Majority (436,367, 83.426%) were damage to property, followed by non-fatal or injurious cases (84751, 16.203%) and fatal outcomes (1941, 0.371%). Drivers have the greatest number of fatalities and injuries compared to passengers and pedestrians. Cars (513482 52.322%) and motorcycles (136641, 13.923%) remain the major types of vehicles involved in road crashes. The factors that were significantly associated with increased odds ratio for driver death were involvement of pedicabs (OR=10.937, p=0.000), motorcycles (OR=55.061, p=0.000), bus (OR=5.835, p=0.000), truck (OR=7.073, p=0.000), hit object (OR=11.007, p=0.000), self-accident (OR=6.149, p=0.000), and collisions in bridges/flyovers (OR=2.713, p=0.010)). The factors that were significantly associated with increased odds ratio for passenger fatality were the involvement of motorcycle (OR=3.75, p=0.021), angle impact (OR=42.01, p=0.002), multiple collision (OR=18.42, p=0.040), self-accident (OR=32.66, p=0.010), and lost control (OR=82.98, p=0.001). The factors significantly associated with pedestrian fatality were hit and run (OR=56.04, p=0.000), hit pedestrian (OR=1085.17, p=0.000), and crashes in bridges/flyover (OR=4.20, p=0.025). Meanwhile, multinomial regression showed that classification of crash and vehicle type were significantly associated with fatal and non-fatal crashes.Conclusion. The study showed the trend of fatality and injury among drivers, passengers, and pedestrians from2016-2020, and factors of road crashes in Metro Manila including vehicle type, road behaviors, collision type and junction type.

Trends in internal migration in Japan, 2012-2020: The impact of the COVID-19 pandemic.

In the past 10 years or so, there have been growing concerns in Japan that migration trends, such as large in-migration to the Tokyo metropolitan area (TMA) at the national scale and large movements from the suburbs to the centres at the metropolitan scale, have widened the core-periphery disparities at each scale under national population decline. However, the COVID-19 pandemic led to unexpected changes in these migration patterns, such as a weakened population concentration in the TMA. This study aims to examine internal migration trends from 2012, on axes of core-periphery in Japan and centre-suburbs in metropolitan areas, and the changes in the migration patterns caused by the pandemic in 2020. First, we prepared intermunicipal origin-destination tables by estimating the suppressed flows in 2012-2020 using the iterative proportional fitting technique, and then we calculated the net migration and migration efficiency indices based on seven area types: centre and suburbs of the TMA, centres and suburbs of major metropolitan areas, centres and suburbs of other metropolitan areasand nonmetropolitan areas. The results indicate that the 2020 migration efficiency in the centre of the TMA drastically dropped to the lowest level during the study period, contrasting with an upward trend in 2012-2019. The pandemic strongly affected the migration patterns from/to and within the TMA, with much net gain in the suburbs from the centre, but the impact of migration efficiencies among the other areas was minimal. These findings can help in providing direction for the postpandemic policy challenge of spatial planning in Japan, for example, the weakened but still widening disparities between the TMA and the other regions and the renewed threat of urban sprawl caused by the increased migration from the centre to the suburbs within the TMA.

Honour Killing in Shakespeare. By Loraine Fletcher

As Loraine Fletcher admits, “Shakespeare Our Contemporary” arguments of the sort advanced by Jan Kott and numerous later critics can easily misfire, or else trivialize the plays they seek to rescue for modern eyes and minds (85). Yet, when it comes to the violent victimization of women through false accusations bred in the soil of misogyny, today’s world daily restages Elizabethan and Jacobean plot-lines—in metropolitan centers as much as in distant borderlands. Britain’s National Police Chiefs’ Council reports that, in 2020–2021, 120 women died in the UK alone as a result of domestic violence, more than two per week, with most aged between 25 and 54 years and “the most common cause of death being by a sharp instrument” (https://news.npcc.police.uk/releases/domestic-homicides-show-no-significant-increase-during-lockdown-says-new-police-report). In Honour Killing in Shakespeare, Fletcher blames the ingrained patterns of a patriarchal culture that fixed in minds, norms, and laws “an entrenched image of women as frivolous, stupid or weak, and therefore prone to infidelity” (189). Hence the persistence and recurrence of honor-killing itself—or else its threat and thwarted preparation—by outraged lovers, spouses, or parents in Shakespeare’s plays, from Titus Andronicus to All is True (Henry VIII). Like many critics, Fletcher places the plays’ author decisively on the side of empathy and enlightenment. Shakespeare makes us “spectators at a judgement” where “misogyny itself” is on trial (310). In every case that matters, “we know the woman is wrongly accused” (19) of fornication or adultery. The playwright consistently “rejects the narrative of female weakness and deceit” (328). He forces his audience to “confront the madness” that spurs deluded angry men to destroy innocent but “embattled women” (328). A dedicated debunker of the “Eve stereotype,” Shakespeare presents his female characters as “candid and loyal”—with some “notable exceptions” (211). Even so, no one can accuse Lady Macbeth of failing to support her spouse.

Real-World Safety and Health Care Resource Utilization Analysis of Venetoclax and Hypomethylating-Agent Treatment for AML in an Academic-Affiliated Urban Community Oncology Network

Introduction Acute Myeloid Leukemia (AML) is a disease that affects predominantly older patients with a median age at diagnosis of 68 years. Elderly patients often have medical comorbidities and are ineligible for intensive induction chemotherapy. Recently, the FDA approved the combination of HMA/venetoclax for patients with newly diagnosed AML who are 75 years or older, or who have comorbidities precluding intensive induction chemotherapy. Through this retrospective analysis of patients treated at a metropolitan academic leukemia center and academic-affiliated community oncology practice network, our goal was to evaluate the safety and health care resource utilization of HMA/venetoclax treatment in a real-world experience. Methods We performed a retrospective analysis of patients treated for AML with HMA/venetoclax as standard-of-care at UCLA from 2018 to 2021. Patients treated with first-line HMA/venetoclax at UCLA community clinics (CC) and at UCLA main campus (academic centers, AC) and had a treatment record available in the electronic medical system were included. We specifically sought to collect safety parameters. Short-term efficacy outcomes were secondary endpoints. Results Thirty-three patients were eligible for analysis: eleven patients who received care in CC and 22 patients who were treated at AC. Baseline characteristics and treatment information are presented in Table 1. The average age was 76 years old for CC and 71 years old for AC. The proportion of patients older than 60 years old is 100% in CC, and 82% at AC. ECOG performance status was predominantly 0 and 1, irrespective of treatment location. Both groups have predominantly a secondary AML diagnosis (CC 64%, AC 59%). According to ELN 2017 criteria, 36.4% of CC had adverse risk disease, compared to 72% of AC patients. CC patients had median of 30% bone marrow blasts at diagnosis and AC had 59% blasts. Forty percent of CC patients and 64% of AC patients had baseline platelet counts <50x103/uL. Regarding treatment, eight out of 11 CC patients had consultation with a physician from the academic leukemia group. Twenty-seven percent of CC patients and 82% of AC patients were treated inpatient for cycle 1. Eighteen percent of CC patients and 66.6% AC patients received venetoclax at a starting dose lower than 400mg daily. Eighty-six percent of the dose reductions were due to concurrent azoles use. Finally, prophylactic antibiotics were used in 45% of CC patients compared to 64% of AC patients, and antifungal prophylaxis was used in 27% of CC patients compared to 64% of AC patients. Safety data, health care resource utilization, and clinical outcome information are reported in Table 2. The percentage of patients with grade 4 neutropenia duration >30 days after cycle 1 was 50% in CC vs. 43% at AC. There were no deaths before 30 days at CC and there were 2 deaths (10%) in AC. Thirty- to sixty-day mortality was zero in both groups. Thirty-six percent of CC patients and 59% of AC required hospitalization (infectious related: 43% CC, 52% AC; cytopenia: 29% CC, 10% AC). The median number of hospital days was 3 (range, 0-17) in CC, and 27 (range, 6-81) in AC; and 0% of CC vs. 18% of AC patients required an ICU stay. Regarding clinical response, bone marrow biopsy was done after cycle 1 in 91% of CC vs. 41% of AC patients. Of these patients, CR/CRi rate was 80% in CC patients vs. 56% in AC patients. Discussion Our study suggests that AML treatment with HMA/venetoclax can be administered safely in real-world community setting. The high number of CC patients that had consultation with AC group reflects the integrative collaborative practice model at our urban academic affiliated oncology community practice. Patients treated in CC tend to be older, with more favorable AML, and better BM function reserve at baseline. The CR rate for patients treated in CC is comparable to previously published data. The high number of patients treated inpatient for cycle one at AC likely indicates AC carries a more acutely ill AML patient population compared to CC, which likely resulted in more health care resource utilization. It is interesting to observe that in the CC group, 29% of the complications leading to hospitalization are from cytopenia, suggesting that health care resource utilization could be further optimized with pre-emptive transfusion scheduling. Limitations of this analysis include that this is a small, single center, retrospective analysis. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

"Here's What I Wish You Knew": A Qualitative Narrative Analysis of the Adolescent Sickle Cell Pain Experience

Background Bias, stigmatizing language, and social isolation are significant barriers to the optimal care of pain for adolescents and young adults (AYA) with sickle cell disease (SCD). Qualitative studies that include first-person narratives of SCD pain are underrepresented in outcomes research but provide valuable information for clinical education and community care models. Here, we present the interim analysis of an ongoing thematic research study that analyzes narrative experiences of AYA patients with SCD and their journeys- both in and out of the healthcare system- with chronic pain. Methods In this IRB-approved study, a single semi-structured interview is administered to patients ages 13-21 with sickle cell disease (Hemoglobin SS, SC, and SBeta0Thal genotypes) living in a mid-sized metropolitan center and receiving care at an academic teaching hospital. Patients are offered the opportunity to participate from inpatient units, ambulatory continuity clinics, and community advocacy groups. Interviews are conducted either in-person or remotely, recorded, transcribed, and independently checked for accuracy. The interview includes questions about coping with pain in medical and non-medical settings, interactions with the healthcare team, impacts of pain on social and community life, and opportunities to describe what patients wish family members, teachers, friends, and healthcare providers understood about living with SCD pain. Transcripts are analyzed for thematic coding by 2 independent coders using a deductive approach with latent textual analysis (Braun & Clarke, 2013). Codes are translated into themes by key-words-in-context and indigenous categorization methods (Ryan, 2011). Thematic coders are not members of the patients' clinical care teams, and patients do not provide interviews during acute pain crises. Results At the time of submission, 8 interviews were completed and analyzed. The median patient age was 17 years. Concordant coding revealed five primary themes: the relationship between acute and chronic pain, coping with rituals and cycles of care, the unpredictable nature of pain, navigating a biased healthcare system, and social isolation. The majority of patients detailed their experiences with intense, coexistent physical and emotional pain (6/8) that creates a pervasive sense of uncertainty and foreboding (4/8) in their lives. They described navigating a healthcare system that is difficult to understand, while experiencing doubts and dismissals of their pain from healthcare providers, particularly when making the transition to adult care (4/8). Lack of education and awareness about SCD in academic settings (5/8) and "missing out" on social milestones and norms (6/8) were cited as sources of isolation and emotional fatigue. Having a family member or community-based care advocate was viewed as a critical source of support within both the health system and community (4/8). Discussion and Future Directions This ongoing qualitative research study in adolescent and young adults with SCD provides narrative data about the lived experience of sickle cell pain from the patient perspective. Interim analysis suggests several locations in the care trajectory where reports of pain may be particularly vulnerable to bias: in healthcare settings for management of acute-onset pain crisis, in schools and other academic support settings where knowledge of SCD may be incomplete, and in the transition of care from pediatric to adult care models. Particularly during acute pain management and transition care experiences, patients describe the use of stigmatizing language- in conversation and in the electronic health record- that contribute to feelings of isolation, frustration, and emotional suffering. Results of this study are being used to inform community, pastoral, and school-based sickle cell education programs as well as medical education curricula aimed at reducing stigmatizing language. Results are also being used to develop standard criteria for sickle cell patient advocates, and to improve infrastructure for the integration of patient advocates into sickle cell care teams. Future research will measure the impact of patient participation in narrative research on clinical outcomes and attitudes toward engaging the healthcare system, both for routine care and potential SCD clinical research. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Assessment of the validity of international classification of disease tenth revision codes for atopic dermatitis.

Little is known about the validity of ICD-10-CM codes for atopic dermatitis (AD) in healthcare claims databases. We assessed the validity of ICD-10-CM codes for identifying adult patients with AD. The healthcare claims database from a large metropolitan tertiary care medical center was queried for diagnostic codes of L20.x and L30.9. Medical records were reviewed for demographics, comorbidities, Hanifin & Rajka (H-R), and United Kingdom Working Party (UKWP) criteria. Sensitivity, specificity, and positive predictive values (PPVs) were calculated. Overall, 833 patients were identified with ≥ 1 occurrence of the aforementioned ICD-10 codes for AD. Using H-R and UKWP criteria as the gold-standard definitions of AD, the PPV of any aforementioned L20.x ICD-10 codes was 39.1% and 51.4%, with sensitivity of 98.1% and 97.4%, respectively. The PPV was 25% and 50% for L20.82; 66.7% and 100% for L20.84; 37.5% and 62.5% for L20.89; 60.1% and 51.4% for L20.9, respectively. PPV generally increased when case definitions combined ICD-10 codes with coexistent ICD-10 codes for asthma or hay fever, food allergy, and allergic rhinitis, and to a lesser extent coding of the ICD-10 code for AD by a dermatologist. Among patients with all these criteria, PPV increased to 100% and 80% based on H-R and UKWP criteria, but sensitivity decreased to 83.3% and 80.0%, respectively. In conclusion, ICD-10-CM codes for AD alone had poor PPV for identifying AD in a healthcare claims database. Combined ICD-10 codes for AD and comorbid atopic disease improved PPV and specificity of classification at the expense of sensitivity.

Abstract 10044: An Analysis of Thrombectomy Usage Among Different Hospital Types

Introduction: Introduction: Prior studies have shown an increase in utilization of thrombectomy in acute stroke over the past few years. However, the likelihood of a thrombectomy being performed may be different among different hospital types. Methods: Using the National Emergency Department Sample (NEDS) database, we retrospectively queried patients with acute cerebral infarction from 2006 to 2019. Patients were compared based on treatment with or without thrombectomy. Multivariable logistic regression was performed to estimate the odds of thrombectomy based on hospital characteristics to identify disparities in treatment utilization. Results: Of the 2,998,192 patients with an acute stroke, 44,548 (1.49%) had a thrombectomy. Patients treated after 2006 had significantly higher odds of having a thrombectomy, with a stepwise increase in the odds of thrombectomy for each subsequent year. After adjustment for factors such as income status, insurance type, gender, and comorbidities, we found that patients from trauma centers were more likely to undergo thrombectomy than patients admitted to non-trauma centers (Level 1 vs. non-trauma OR 3.06, 95%CI 2.37- 3.95; Level 2 vs. non-trauma OR 1.97, 95%CI 1.42-2.73). Also, patients admitted to metropolitan teaching centers were more likely to have a thrombectomy than patients admitted to non-metropolitan teaching centers (OR 2.77 95%CI 1.80-4.25). Conclusions: The varying degrees of thrombectomy usage may be due to centralized resources and multi-disciplinary care available at larger, urban centers. It could also be explained by the lack of neurointerventionalists who perform thrombectomies in community centers.

The association between implementation of multidisciplinary rounds and clinical outcomes.

Multidisciplinary rounds (MDR) consisting of social workers, dietitians, pharmacists, physical therapists, nurses, and physicians have been implemented at many healthcare institutions to address the complex components of inpatient care. However, little is known on the association of MDR on clinical outcomes across cardiovascular pathologies. This study aimed to investigate the impact of MDR on cardiovascular patients. Hospital admissions to inpatient cardiology were evaluated prior to (November 2017 to November 2018) and after implementation of MDR (December 2018 to August 2020) at a metropolitan academic medical center. The following outcomes were evaluated: clinical complications (incidence of stroke, gastrointestinal bleed, myocardial infarction, or systemic infection during hospitalization), Length of Stay (LOS), 30-day readmissions and all-cause in-hospital mortality. Secondary outcomes included utilization of physical therapy and dietary services. Admissions were evaluated prior to (N = 1054) and after (N = 1659) MDR implementation. All-cause in-hospital mortality after MDR implementation decreased significantly from 2.8 to 1.6% (P = 0.03). Although the number of complications and LOS decreased, these differences were not statistically significant. No significant change was observed in 30-day readmissions. Significant increase in the utilization of physical therapy (34.2 to 53.5%; P < 0.01) and dietary services (7.2 to 19.3%; P < 0.01) were observed. Multidisciplinary rounds implementation was associated with significantly decreased mortality and positively impacted resource utilization with increased consultations for ancillary services. MDR is a high impact intervention that utilizes existing resources to improve mortality and should be implemented especially for cardiovascular patients. Further investigation into the benefit of MDR across different patient populations and care settings is warranted.

Associations Between Race/Ethnicity, Language, and Enrollment on Cancer Research Studies.

The objective of this study was to determine whether differences in patients' race/ethnicity, preferred language, and other factors were associated with patient enrollment in oncology research studies. We conducted a retrospective cross-sectional analysis of all adults (>18 and ≤90) seen at a large, metropolitan cancer center from 2005 to 2015, examining if enrollment to a research study, varied by race/ethnicity, preferred language, comorbidities, gender, and age. A total of 233 604 patients were available for initial analysis. Of these, 93 278 (39.9%) were enrolled in a research protocol (therapeutic and non-therapeutic studies). Patients who self-reported their race/ethnicity as Native, Other, Unknown, or Refuse to Answer were less likely to be enrolled on a study. Patients with one or more comorbidities, and those whose preferred language was English, were more likely to be enrolled on a research study. A logistic regression model showed that, although Non-Hispanic Black patients were more likely to have one or more comorbidities and had a higher proportion of their subset selecting English as their preferred language, they were less likely to be enrolled on a study, than our largest population, Non-Hispanic/White patients. We identified differences in research study enrollment based on preferred language, and within race/ethnicity categories including Native-Populations, Other, Unknown or Refuse to Answer compared to Non-Hispanic/White patients. We also highlighted the lower odds of enrollment among Non-Hispanic/Black patients, in the setting of factors such as comorbidities and English language preference, which were otherwise found to be positive predictors of enrollment. Further investigation is needed to design targeted interventions to reduce disparities in oncology research study enrollment, with particular focus on language diversity.

Oncology nurse perceptions about life expectancy discussions: a cross-sectional study exploring what patients want to know, and why doctors don’t disclose

Background: Sensitive and patient-centred discussion about life expectancy has clear benefits for patients with advanced cancer and their families. The perceptions of oncology nurses about disclosure of life expectancy, and the barriers to disclosure, have rarely been explored. Objectives/Aims/Hypotheses: To examine oncology nurses’ perceptions of the: (1) proportion of patients with advanced cancer who want, receive and understand estimates of life expectancy; (2) reasons why doctors may not provide estimates of life expectancy. Design: Cross-sectional survey. Methods: Australian oncology nurses who were members of a professional society or worked at a participating metropolitan cancer centre were emailed a link to an anonymous online survey. Participants provided socio-demographic characteristics and their perceptions about the proportion of patients with advanced cancer who (a) want, (b) are provided with, (c) receive and (d) understand estimates of life expectancy, as well as the reasons estimates of life expectancy may not be provided. Results: A total of 104 nurses participated. While 51% of nurses perceived that most patients (>75%) want to be provided with an estimate of their life expectancy, 63% of nurses reported that <50% of patients were provided with an estimate. Further, 85% of nurses indicated that <50% of patients understand the estimate. The most frequent reason nurses perceived doctors did not provide an estimate of life expectancy was because the doctor didn’t have an accurate idea of life expectancy (80.8%). Almost one-fifth of nurses (18.3%) thought that doctors did not provide estimates because they felt it was not their responsibility to do so. Conclusions: Strategies to ensure a patient-centred approach to life expectancy discussions with patients with advanced cancer are urgently needed. Impact statement: Oncology nurses perceive that many patients with advanced cancer are not provided with an accurate estimate of their life expectancy and few understand the information provided to them.

Methodology for Photovoltaic Plant Modeling with RETScreen Software application

In today's world, the search for new energy generation alternatives is increasing and being far from large metropolitan centers is an aggravating factor for the socioeconomic development of municipalities. In addition to the difficulty and high costs of keeping a city in proper working order, the quality of service provided by electricity concessionaires has low efficiency and high consumption of fossil fuels. In order to contribute to a solution, this work aims to present an alternative developed using the RETScreen Software, through the design of a photovoltaic plant, to meet the energy demands of the municipalities in the state of Amazonas. Through the research, we sought to understand and present the particularities of each proposed chapter and, through computer simulation, to develop a renewable source plant to supply the demand of the municipality of São Gabriel da Cachoeira-AM. Two possibilities of application of the result can be analyzed, where the fulfillment of the demand was carried out in a total and partial way and, with that, obtain satisfactory results such as the reduction of 50% of the consumption of fossil fuel, reduction of 25% to 50 % of emission of polluting gases and to present the potential that the generation of photovoltaic energy has for the Amazon region.

Before Equal Protection: The Fall of Cross-Dressing Bans and the Transgender Legal Movement, 1963–86

AbstractScholars are still unsure why American cities passed cross-dressing bans over the closing decades of the nineteenth century. By the 1960s, cities in every region of the United States had cross-dressing regulations, from major metropolitan centers to small cities and towns. They were used to criminalize gender non-conformity in many forms - for feminists, countercultural hippies, cross-dressers (or “transvestites”), and people we would now consider transgender. Starting in the late 1960s, however, criminal defendants began to topple cross-dressing bans.The story of their success invites a re-assessment of the contemporary LGBT movement’s legal history. This article argues that a trans legal movement developed separately but in tandem with constitutional claims on behalf of gays and lesbians. In some cases, gender outlaws attempted to defend the right to cross-dress without asking courts to understand or adjudicate their gender. These efforts met with mixed success: courts began to recognize their constitutional rights, but litigation also limited which gender outlaws could qualify as trans legal subjects. Examining their legal strategies offers a window into the messy process of translating gender non-conforming experiences and subjectivities into something that courts could understand. Transgender had to be analytically separated from gay and lesbian in life and law before it could be reattached as a distinct minority group.