White River Junction Research Articles

At Work in the Ruins: Finding Our Place in the Time of Science, Climate Change, Pandemics and All the Other Emergencies by Dougald Hine

Reviewed by: At Work in the Ruins: Finding Our Place in the Time of Science, Climate Change, Pandemics and All the Other Emergencies by Dougald Hine John Zerzan DOUGALD HINE At Work in the Ruins: Finding Our Place in the Time of Science, Climate Change, Pandemics and All the Other Emergencies White River Junction, Vermont. Chelsea Green. 2023. 224 pages. WITH AN UNWIELDY subtitle for a somewhat unwieldy book, At Work in the Ruins is largely a continuation or an updating of an essay Dougald Hine co-authored with Paul Kingsnorth in 2009, "Uncivilisation: The Dark Mountain Manifesto." At Work in the Ruins is wide-ranging, drawing from a myriad of conversations, talks, books, and observations. It is not a hopeful book, and an overarching challenge seems to be responding to the charge that he and Kingsnorth have surrendered, have given up any hope of ultimately coming out on top in this time of great crisis. The context for the book: Hine's better-known colleague, Kingsnorth, set the stage more than a decade ago. Turning away from his Dark Mountain activism, Kingsnorth decided that environmental collapse was inevitable. He became quite sympathetic to Brexit, and later to the anti-vaxxers; he converted to the Romanian Orthodox Church. Kingsnorth's change of orientation was rewarded by New York Times Magazine with a long, favorable piece titled "It's the End of the World as We Know It . . . and He Feels Fine" (2014). Hine has not gone as far off the rails as his close colleague, but it is clear that he is no longer a battler against the deepening Dead Zone that is today's reality. One giveaway is his constant use of the term "climate change," on pretty much every page of At Work in the Ruins. Climate change is a weak euphemism for the unfolding overall catastrophe, a telling usage. There are, however, worthy explorations undertaken in the book. Hine repeatedly returns to science as a problematic project rather than as some kind of saving grace. [End Page 80] He not only claims that we ask too much of it but that the culture of science is itself limiting. Hine suggests that the Covid pandemic presented us with a fork in the road, the possible emergence of a new politics of science. He points out that science has not proven to be an effective safeguard against misinformation but does not provide much as to what a new way of approaching science would look like. At Work in the Ruins acknowledges that science "is behind the project of making this living planet into an object of technological management and control" but doesn't linger with that insight or develop it. Hine also notices, in passing, the costs of industrial modernity and asks, "Is this the way to inhabit a planet?" Hine surveys some of the shallow and false paths to comprehending or challenging our predicament—and then follows suit, in my opinion, with a major failure of his own. Fifty pages in, he sees 2018 as "a great opening," with the appearance of Jem Bendell's Deep Adaptation thesis and the emergence of the Extinction Rebellion protest movement. But the two phenomena seem contradictory or opposed. Bendell sees collapse as inevitable, while Extinction Rebellion counsels nonadaptation: "In the face of extinction, we say Rebellion!" In January 2023 E.R. abandoned disruptive protests as a tactic and hasn't offered much by way of radical analysis. Hine lauds Greta Thunberg and Joe Biden in his chapter "Here Come the Grown-Ups." Odd choices for a liberatory future. Thunberg represents moral protest minus action, and Biden is a more than obvious case of status quo as matters get graver ever faster. Hine hops around throughout the book with scores of passing references to recent years. In search of a contrasting energy, he might have considered going back a bit further: to the antiglobalization movement of 1999-2001, for example, that raged in such places as Eugene, Seattle, Quebec City, Prague, and Genoa. That last location saw three hundred thousand in the streets and all-out fighting. No mention of this phenomenon by Hine. In the chapter "Shades of Denial," Hine debunks...

Development and Validation of a Clinical Risk Score to Predict Hospitalization Within 30 Days of Coronavirus Disease 2019 Diagnosis.

ABSTRACTIntroductionEarly identification of patients with coronavirus disease 2019 (COVID-19) who are at risk for hospitalization may help to mitigate disease burden by allowing healthcare systems to conduct sufficient resource and logistical planning in the event of case surges. We sought to develop and validate a clinical risk score that uses readily accessible information at testing to predict individualized 30-day hospitalization risk following COVID-19 diagnosis.MethodsWe assembled a retrospective cohort of U.S. Veterans Health Administration patients (age ≥ 18 years) diagnosed with COVID-19 between March 1, 2020, and December 31, 2020. We screened patient characteristics using Least Absolute Shrinkage and Selection Operator logistic regression and constructed the risk score using characteristics identified as most predictive for hospitalization. Patients diagnosed before November 1, 2020, comprised the development cohort, while those diagnosed on or after November 1, 2020, comprised the validation cohort. We assessed risk score discrimination by calculating the area under the receiver operating characteristic (AUROC) curve and calibration using the Hosmer–Lemeshow (HL) goodness-of-fit test. This study was approved by the Veteran’s Institutional Review Board of Northern New England at the White River Junction Veterans Affairs Medical Center (Reference no.:1473972-1).ResultsThe development and validation cohorts comprised 11,473 and 12,970 patients, of whom 4,465 (38.9%) and 3,669 (28.3%) were hospitalized, respectively. The independent predictors for hospitalization included in the risk score were increasing age, male sex, non-white race, Hispanic ethnicity, homelessness, nursing home/long-term care residence, unemployed or retired status, fever, fatigue, diarrhea, nausea, cough, diabetes, chronic kidney disease, hypertension, and chronic obstructive pulmonary disease. Model discrimination and calibration was good for the development (AUROC = 0.80; HL P-value = .05) and validation (AUROC = 0.80; HL P-value = .31) cohorts.ConclusionsThe prediction tool developed in this study demonstrated that it could identify patients with COVID-19 who are at risk for hospitalization. This could potentially inform clinicians and policymakers of patients who may benefit most from early treatment interventions and help healthcare systems anticipate capacity surges.

Transformation for sustainability: a deep leverage points approach

Change and transformation of human systems are increasingly seen as the fundamental solution space for treating the root causes of unsustainability. What does transformation of human systems for sustainability exactly mean and entail, and how to effectively transform human systems? This paper addresses these essential questions in a holistic, systems thinking approach following and extending the leverage points tool for systemic change proposed by Meadows (Thinking in Systems: a primer. Chelsea Green Publishing, White River Junction, 2008). The paper focuses on the often unquestioned, largely unconscious, systemic realm of mental models and human intent. It targets Meadows’ deepest leverage points of purpose and paradigm; beyond, it deals with worldview, core metaphor, and human thinking. The fundamental outcome of this conceptual study is that unsustainability roots in a cognitive illusion coupled to a lack of teleological thinking. Transformation needs us to see and reconceive the human–world bond through the systemic lens of dynamic inclusion, aliveness, purpose and value. Learning to think in terms of living systems, physical and mental, and substituting the iceberg metaphor-in-use in conventional systems thinking with a holistic metaphor of nested leverage points are the first transformation steps toward a new sustainability paradigm. Practical evidence and ecological content come from the transformative design discipline of biomimicry, which consciously turns to nature as the source of its conceptual system. The paper concludes that transformative practice for sustainability will gain momentum by braiding together systems thinking in practice and biomimicry thinking. In sum, this transdisciplinary approach opens up exciting research horizons in ontological, epistemological, methodological and teleological directions.

Ritdómur: 2052: A Global Forecast for the Next Forty Years

2052: A Global Forecast for the Next Forty Years, eftir Jørgen Randers, White River Junction: Chelsea Green Publishing, 2012, 392 bls.

Farming While Black: Soul Fire Farms Practical Guide To Liberation on the Land by Leah Penniman and Karen Washington

Reviewed by: Farming While Black: Soul Fire Farms Practical Guide To Liberation on the Land by Leah Penniman and Karen Washington C. K. Cartagena Farming While Black: Soul Fire Farms Practical Guide To Liberation on the Land. Leah Penniman and Karen Washington. Chelsea Green Publishing, White River Junction, VT, 2018. 355 pp.; resources, charts, diagrs., ills., notes, photos, and index. $34.95. (ISBN 978-1-60358-761-7). Farming While Black is a step by step guide for the modern-day Black farmer with historical accounts exploring the struggles and solutions encountered by past Black farmers who lived under both oppression from the state and their counterparts. A manual for operating in the realm of land stewardship is necessary when racial discrimination in the farming sector resulted in a class action lawsuit against the United States Department of Agriculture, as in the case of Pigford v. Glickman (Daniel 2013). Even the mere act of growing food as a Black person separate from corporate commodification was met with violence, in the case of Ron Finley of California (Ron Finley Project 2020) who dealt with over-policing of his property by the City of Los Angeles. Farming While Black acts as a comprehensive guide for aspiring and practicing Black farmers that offers a variety of instruction: obtaining land and resources, outlining farm business plans, honoring spirits of the land, land restoration, crop planning, preserving harvests and seeds, raising animals, urban farming, movement building through education, and action and policy change. Penniman has done extensive research and included personal documentation to identify land-based movements of oppressed populations throughout the world that coincide with the outline of this book. It serves as an acknowledgment of obstacles faced by many Black farmers and a welcome home to so many people who have been discouraged and rejected by land stewards and workers through entities such as banks and farmers markets. This book is a radical and educational option from Soul Fire Farms, a Black- and Indigenous-centered community farm in Rensselaer County, New York (Penniman and Washington 2018). As a guide, the book seeks to offer itself as a reference for sustaining productive farmland and activism through the lens of a desire to obtain land autonomy for Black people of the African diaspora. Farming While Black exposes to the reader a plethora of sustainability initiatives, particularly throughout the North and South American continents. Such initiatives exist because food and land are desired amongst Black people seeking sovereignty from violent statist structures and resisting food apartheids, [End Page 183] defined as “segregation that relegates certain groups to food opulence and prevents others from accessing life-giving nourishment” (Penniman and Washington 2018). Refugees, immigrants, residents of food apartheid areas, and formerly-incarcerated folks are particularly in need of initiatives of this kind, where fresh food is provided. This need arises out of a right to nutritious food, but especially for those most vulnerable to the highest levels of disease and food insecurity. The Black Radical Tradition is a Pan-Africanist and Indigenous frame of reference that historically sought land for its people. This initiative occurs as an element of the Black radical tradition: addressing the geopolitical ontology of the Black population through advocating for and obtaining spatial existence. Political power, stemming from geographic space, defined as “organized locations where social relations are fostered and maintained” (Razack 2002) is how spatial existence is formalized and often recognized in the field of political geography. Penniman illustrates spatial existence in more informal terms using this frame of reference. According to Priscilla McCutcheon, by pairing the Black Radical Tradition and feminist geopolitical ideologies, discussions of Black spirituality and agrarianism (McCutcheon 2019) are more accurately understood. One of the overarching elements that separates this book from others like it is the attention paid to spirituality. This storytelling move is framed by collectivism, an informal, bottom-up approach to conducting business (Secor 2001). Penniman recants her own ethnic identity, “my family’s mixed ethnic heritage” (Penniman and Washington 2018), where identity is tied to cultural practices that have helped shape the spirituality of African diasporic people and a strenuous relationship with the land due to colonialism. This understanding of the body as mixed...

Tiger talk

Tiger talk

Latent factor structure of DSM-5 posttraumatic stress disorder: Evaluation of method variance and construct validity of novel symptom clusters.

[Correction Notice: An Erratum for this article was reported online in Psychological Assessment on Nov 19 2018 (see record 2018-60122-001). In the article, the affiliations of multiple authors were incorrectly listed in the author byline and author note. For Daniel J. Lee, Michelle J. Bovin, Denise M. Sloan, Terence M. Keane, and Brian P. Marx, the affiliations should have read "National Center for PTSD, Boston, Massachusetts; VA Boston Healthcare System, Boston, Massachusetts; and Department of Psychiatry, Boston University School of Medicine." For author Paula P. Schnurr, the affiliations should have read "National Center for PTSD, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth." All versions of this article have been corrected.] The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) 4-factor model of posttraumatic stress disorder (PTSD) has demonstrated adequate fit in several confirmatory factor analysis (CFA) studies. Although several alternative measurement models have demonstrated better fit, there is no consensus yet on the best model, and newly proposed models lack sufficient construct validation. Notably, these studies have relied exclusively on questionnaire data, and thus their findings may be attributable to a method effect. This study examined the factor structure of DSM-5 PTSD symptoms using both questionnaire and interview data to determine the impact of assessment method on factor structure and construct validity of alternative model symptom clusters. Participants (N = 380) were veterans who completed the PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013). Fit was similar across models. However, the seven-factor Hybrid model (Armour et al., 2015) fit best. Limited evidence of a method effect was observed. Results of construct validity analyses were mixed; some of the newly proposed symptom clusters demonstrated hypothesized differential associations with external correlates, but others did not. These findings suggest that results of previous DSM-5 PTSD CFAs supporting the Hybrid model are not attributable to a method effect. However, observed limited difference in model fit and mixed construct validity evidence raise concerns regarding the value of parsing DSM-5 symptom clusters. Constructs implied by the new factors in the more complex measurement models of PTSD require greater explication and construct validation. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The Community Food Forest Handbook: How to Plan, Organize and Nurture Edible Gathering Places eds. by Catherine Bukowski and John Munsell

Reviewed by: The Community Food Forest Handbook: How to Plan, Organize and Nurture Edible Gathering Places eds. by Catherine Bukowski and John Munsell Nancy Hoalst-Pullen The Community Food Forest Handbook: How to plan, organize and Nurture edible Gathering places. By Catherine Bukowski and John Munsell. Chelsea Green Publishing. White River Junction, VT, 2018. 242 pp.; maps, diagrs., ills., photos, notes, bibliog., index. $24.95 paperback (ISBN 9781603586443) We humans have committed, perhaps inherently, to two things throughout much of our mercurial, labyrinthine history— that we live together in communities, and that we nurture edible landscapes for our own needs. However, with the 19th century rise and displacement of rural agrarian societies by urban industrial ones, our natural relationships with food sources (and forests) have declined. Although, and perhaps not ironically, urban gardens proliferated in the 1890s by way [End Page 99] of civic organizations and predominantly middle and upper-class women. Indeed, forests and gardens have become so intensely maintained and transformed from their natural state that we don't readily recognize or accept the complexities and interconnectedness of species living in a given environment. Fortunately, increased social awareness and activist approaches to understanding and encountering nature, especially at the community level, make Bukowski and Munsell's book a solid read for those interested in developing and growing perennial edible yields by way of community planning, engagement and stewardship of these food forests. As the subtitle states, the book provides a scholarly guide on how to organize and operate the social factors that affect the development, installation and maintenance of community food forest gardens. The observations, interviews and meetings from the twenty or so projects underscore what works in making these spaces sustainable, civic interests for a given community and its stakeholders. Bukowski and Munsell offer various opportunities to define and cognize the multifaceted and sometimes complex territory of what does—and does not—constitute a community food forest. The fundamental framework of designing and managing food forests at the community scale, which integrates ecological and social systems, is explained as the three "ingredients," which include the function (or purpose), elements (of the system), and the connections between the elements. Underlying some of this discussion includes concepts from Donella Meadows' (2008) insightful Thinking in Systems: A Primer, which establish the innate relationships between action and behavior. Additionally, ecological and evolutionary terms more commonly used in explaining the changes of a forest (e.g. natural succession) are reflected appropriately with the people, organizations, and various cultural and social underpinnings that lend to the success(es) or failure(s) of a given community food forests. Don't be fooled by the first few paragraphs; the introduction feels like a second person "choose your own adventure" read. However, this immersive language does well to establish a sensory understanding of what a community food forest can be, without necessarily having any empirical knowledge of it. But this style of writing morphs quickly into an expected academic tone suitable for both the content and perceived audience. Indeed, the structure and content lend this book to be a useful read for city planners, urban foresters, environmental activists, community advocates, university students, and any individual or group of individuals invested in the potential for social and environmental change. The handbook is divided into four sections, each with chapters that contains an assortment of social-ecological concepts, hands-on tools for community engagement, and relevant "real world" examples. Interspersed within these four sections are expanded case studies of community food forests projects from the United States. While the links between the chapter concepts and case studies are not always as prevalent as they could (or should) be, they are great examples on how forest projects develop and evolve with community support. Throughout the chapters, little sidebars provide additional information that is interesting enough to feel like a comfortable diversion from the main text. The first section, entitled Understanding Community Food Forests, covers the [End Page 100] basics of the book, by first establishing the function (purpose) and historical context of these (predominately) urban forests gardens. Bukowski and Munsell attribute certain historic markers for their recent expansion and adoption of community food forests, including the collapse of the...

"Latent factor structure of DSM–5 posttraumatic stress disorder: Evaluation of method variance and construct validity of novel symptom clusters": Correction to Lee et al. (2018).

Reports an error in "Latent factor structure of DSM-5 posttraumatic stress disorder: Evaluation of method variance and construct validity of novel symptom clusters" by Daniel J. Lee, Michelle J. Bovin, Frank W. Weathers, Patrick A. Palmieri, Paula P. Schnurr, Denise M. Sloan, Terence M. Keane and Brian P. Marx (Psychological Assessment, Advanced Online Publication, Aug 16, 2018, np). In the article, the affiliations of multiple authors were incorrectly listed in the author byline and author note. For Daniel J. Lee, Michelle J. Bovin, Denise M. Sloan, Terence M. Keane, and Brian P. Marx, the affiliations should have read "National Center for PTSD, Boston, Massachusetts; VA Boston Healthcare System, Boston, Massachusetts; and Department of Psychiatry, Boston University School of Medicine." For author Paula P. Schnurr, the affiliations should have read "National Center for PTSD, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth." All versions of this article have been corrected. (The following abstract of the original article appeared in record 2018-39805-001.) The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) 4-factor model of posttraumatic stress disorder (PTSD) has demonstrated adequate fit in several confirmatory factor analysis (CFA) studies. Although several alternative measurement models have demonstrated better fit, there is no consensus yet on the best model, and newly proposed models lack sufficient construct validation. Notably, these studies have relied exclusively on questionnaire data, and thus their findings may be attributable to a method effect. This study examined the factor structure of DSM-5 PTSD symptoms using both questionnaire and interview data to determine the impact of assessment method on factor structure and construct validity of alternative model symptom clusters. Participants (N = 380) were veterans who completed the PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013). Fit was similar across models. However, the seven-factor Hybrid model (Armour et al., 2015) fit best. Limited evidence of a method effect was observed. Results of construct validity analyses were mixed; some of the newly proposed symptom clusters demonstrated hypothesized differential associations with external correlates, but others did not. These findings suggest that results of previous DSM-5 PTSD CFAs supporting the Hybrid model are not attributable to a method effect. However, observed limited difference in model fit and mixed construct validity evidence raise concerns regarding the value of parsing DSM-5 symptom clusters. Constructs implied by the new factors in the more complex measurement models of PTSD require greater explication and construct validation. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Using an Inpatient Quality Improvement Curriculum for Internal Medicine Residents to Improve Pneumococcal Conjugate Vaccine Administration Rates

Pneumococcal infections are an important source of morbidity and mortality in older adults and persons with compromised immune systems. New recommendations from the Advisory Committee on Immunization Practices (ACIP) became available September 2014, which included recommendations for the use of the 13-valent pneumococcal conjugate vaccine (PCV13). A study was conducted to increase the PCV13 vaccination rates of hospitalized patients at the White River Junction Veterans Affairs Medical Center (White River Junction, Vermont) through the use of a resident-driven quality improvement (QI) project. From December 2014 through April 2016, 16 internal medicine inpatient residents addressed inpatient PCV13 vaccination rates by participating in the facility's QI curriculum. Eight Plan-Do-Study-Act cycles were used, including discharge template editing, electronic reminders, and the discovery of a vaccination administration documentation error in the record through data validation. The measure was the monthly percentage of patients who received PCV13 vaccination (vaccination completion rate) of those discharged from the hospital medicine service who were due for PCV13 vaccination. The percentage of veterans discharged with an up-to-date PCV13 vaccination on discharge increased from approximately 30% to 87% and was sustained. Despite being driven by many different residents, this project demonstrates that continuous improvement can be achieved through a structured and iterative process while providing active learning of core QI concepts to residents. It also displays a method in which new guidelines can be incorporated into practice in an effective manner. Finally, this project is an example of how resident-driven data validation can lead to further improvement.

VA's National PTSD Brain Bank: a National Resource for Research.

The National PTSD Brain Bank (NPBB) is a brain tissue biorepository established to support research on the causes, progression, and treatment of PTSD. It is a six-part consortium led by VA's National Center for PTSD with participating sites at VA medical centers in Boston, MA; Durham, NC; Miami, FL; West Haven, CT; and White River Junction, VT along with the Uniformed Services University of Health Sciences. It is also well integrated with VA's Boston-based brain banks that focus on Alzheimer's disease, ALS, chronic traumatic encephalopathy, and other neurological disorders. This article describes the organization and operations of NPBB with specific attention to: tissue acquisition, tissue processing, diagnostic assessment, maintenance of a confidential data biorepository, adherence to ethical standards, governance, accomplishments to date, and future challenges. Established in 2014, NPBB has already acquired and distributed brain tissue to support research on how PTSD affects brain structure and function.

Adam Federman: <i>Fasting and Feasting. The Life of Visionary Food Writer Patience Gray</i>

Adam Federman: Fasting and Feasting. The Life of Visionary Food Writer Patience Gray: Chelsea Green Publishing, White River Junction, Vermont, 2017: 400 pp., hardback, £20.00.

"Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans": Correction to Bovin et al. (2016).

Reports an error in "Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans" by Michelle J. Bovin, Brian P. Marx, Frank W. Weathers, Matthew W. Gallagher, Paola Rodriguez, Paula P. Schnurr and Terence M. Keane (Psychological Assessment, 2016[Nov], Vol 28[11], 1379-1391). In the article, the departments and affiliations were incorrectly listed for authors Michelle J. Bovin, Brian P. Marx, Matthew W. Gallagher, Paola Rodriguez, Paula P. Schnurr, and Terence M. Keane. The first department and affiliation for authors Michelle J. Bovin, Brian P. Marx, Matthew W. Gallagher, Paola Rodriguez, and Terence M. Keane and should have read "National Center for PTSD at VA Boston Healthcare System, Boston, Massachusetts". The first department and affiliation for author Paula P. Schnurr should have read "National Center for PTSD, White River Junction, Vermont." The online version of this article has been corrected. (The following abstract of the original article appeared in record 2015-55809-001.) This study examined the psychometric properties of the posttraumatic stress disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5; Weathers, Litz, et al., 2013b) in 2 independent samples of veterans receiving care at a Veterans Affairs Medical Center (N = 468). A subsample of these participants (n = 140) was used to define a valid diagnostic cutoff score for the instrument using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013) as the reference standard. The PCL-5 test scores demonstrated good internal consistency (α = .96), test-retest reliability (r = .84), and convergent and discriminant validity. Consistent with previous studies (Armour et al., 2015; Liu et al., 2014), confirmatory factor analysis revealed that the data were best explained by a 6-factor anhedonia model and a 7-factor hybrid model. Signal detection analyses using the CAPS-5 revealed that PCL-5 scores of 31 to 33 were optimally efficient for diagnosing PTSD (κ(.5) = .58). Overall, the findings suggest that the PCL-5 is a psychometrically sound instrument that can be used effectively with veterans. Further, by determining a valid cutoff score using the CAPS-5, the PCL-5 can now be used to identify veterans with probable PTSD. However, findings also suggest the need for research to evaluate cluster structure of DSM-5. (PsycINFO Database Record

Brian Sutton-Smith (1924–2015)

Brian Sutton-Smith, one of the leading scholars of play studies for more than half a century, passed away Mar 7, 2015, in White River Junction, Vermont, at the age of 90. From his active childhood to his highly productive career and retirement, Brian took play very seriously. After identifying the triviality barrier that keeps adults from taking children's play seriously, he put a huge amount of energy into breaking down that barrier. Like the anthropologist Margaret Mead, he achieved remarkable success in reaching both the public and scholars across the disciplines: folklorists, psychologists, anthropologists, and others. He was also an extremely kind, generous colleague whose sheer exuberance made interdisciplinary play studies great fun. As an active member of the American Folklore Society and the Anthropological Association for the Study of Play, Brian had a strongly positive influence on conferences and publications.

Clinical and Educational Outcomes of an Integrated Inpatient Quality Improvement Curriculum for Internal Medicine Residents

Integrating teaching and hands-on experience in quality improvement (QI) may increase the learning and the impact of resident QI work. We sought to determine the clinical and educational impact of an integrated QI curriculum. This clustered, randomized trial with early and late intervention groups used mixed methods evaluation. For almost 2 years, internal medicine residents from Dartmouth-Hitchcock Medical Center on the inpatient teams at the White River Junction VA participated in the QI curriculum. QI project effectiveness was assessed using statistical process control. Learning outcomes were assessed with the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) and through self-efficacy, interprofessional care attitudes, and satisfaction of learners. Free text responses by residents and a focus group of nurses who worked with the residents provided information about the acceptability of the intervention. The QI projects improved many clinical processes and outcomes, but not all led to improvements. Educational outcome response rates were 65% (68 of 105) at baseline, 50% (18 of 36) for the early intervention group at midpoint, 67% (24 of 36) for the control group at midpoint, and 53% (42 of 80) for the late intervention group. Composite QIKAT-R scores (range, 0-27) increased from 13.3 at baseline to 15.3 at end point (P < .01), as did the self-efficacy composite score (P < .05). Satisfaction with the curriculum was rated highly by all participants. Learning and participating in hands-on QI can be integrated into the usual inpatient work of resident physicians.

VA Telemedicine: An Analysis of Cost and Time Savings

The Veterans Affairs (VA) healthcare system provides beneficiary travel reimbursement ("travel pay") to qualifying patients for traveling to appointments. Travel pay is a large expense for the VA and hence the U.S. Government, projected to cost nearly $1 billion in 2015. Telemedicine in the VA system has the potential to save money by reducing patient travel and thus the amount of travel pay disbursed. In this study, we quantify this savings and also report trends in VA telemedicine volumes over time. All telemedicine visits based at the VA Hospital in White River Junction, VT between 2005 and 2013 were reviewed (5,695 visits). Travel distance and time saved as a result of telemedicine were calculated. Clinical volume in the mental health department, which has had the longest participation in telemedicine, was analyzed. Telemedicine resulted in an average travel savings of 145 miles and 142 min per visit. This led to an average travel payment savings of $18,555 per year. Telemedicine volume grew significantly over the study period such that by the final year the travel pay savings had increased to $63,804, or about 3.5% of the total travel pay disbursement for that year. The number of mental health telemedicine visits rose over the study period but remained small relative to the number of face-to-face visits. A higher proportion of telemedicine visits involved new patients. Telemedicine at the VA saves travel distance and time, although the reduction in travel payments remains modest at current telemedicine volumes.

Influenza vaccination rates for hospitalised patients: a multiyear quality improvement effort

BackgroundInfluenza vaccination is the most effective method for preventing influenza virus infection. Adult hospitalised patients form a particularly high-risk group for severe influenza given their advanced age and comorbidities. We...

The Salted Leg

The Salted Leg Gary Lee Miller (bio) Click for larger view View full resolution Photo by Andrew J. Russell, Library of Congress And so it came to be that on the evening of July 24, 1865, Joshua Clantz, formerly of Kaskaskia, Illinois, and the Army of the Potomac, arrived at the Post Mills, Vermont, home of Mr. and Mrs. Emil Picard wearing the remains of his Union uniform and carrying a half-melted packet of Clark’s Maple Sugar Candies, seven forlorn oxeye daisies, [End Page 16] a four-shot pepperbox revolver and the left leg of Private First Class Orlin MacDonald, sawed off just below the knee and coffined in a crate of white Liverpool salt. Scarce a month past eighteen, Clantz had walked all night on the dirt road from White River Junction, where the Connecticut and Passumpsic Railroad coach had disgorged him at half past three that afternoon following a journey from Springfield, Massachusetts, haunted by half sleep and heart-stitching nightmares. That was the usual progression of affairs. Clantz rarely closed his eyes for more than ten minutes’ slumber before murderous visions of Fredericksburg or the Wilderness fantodded him awake, and he’d come to accept the tilted, gauzy world he drifted through in his waking hours. Sometimes, even as he stood, images of the war swarmed him, and he’d faint away, awakening to a new perspective, the rut of a wagon track, say, or the floury dust of the regimental parade ground. On his person, Joshua Clantz carried, excepting the $3,000 in Confederate scrip he had collected in case that currency should one day arise from its worthless state, just eighteen cents, wrapped in a kerchief and tucked in his peg-soled campaign boot. He’d spent a nickel on the candies at the dry goods store opposite the train station and consumed several of those but hadn’t eaten otherwise for the better part of two days; the pepperbox, tucked inside his coat pocket where a highwayman might not notice it, banged against his bony ribs like a hammer on a bell. As he mounted the broad wooden porch, he wished in the way of a soldier—without hope—for two things. First, that Miss Sophie Picard would not hate him too bitterly for the burden he was about to deliver, for he had a mind to woo her. Second, that the smell of stewing fowl tendered on the damp air meant he would be asked to dinner, a prospect he nonetheless dreaded. The War, which he had left behind in some ways but not the least in others, had queered him for polite company, and even for company that was impolite. Hendrikson, the regimental quartermaster, had not only provided the salt in which Orlin MacDonald’s amputated leg rested but had fashioned a shoulder harness for its hemlock sarcophagus from a pair of leather rifle slings. Clantz loosened the slings, shucked the wooden crate from his shoulders and lowered it to the floor. He pushed his dark, suety hair behind his ears, made the most serene countenance he could from his ruddy, pockmarked face, stood up to his full height, which wasn’t but five foot six, and hammered vigorously on the door. [End Page 18] The woman who answered was a matron of fifty, dressed in an olive-hued store-bought dress and a tidy white apron, auburn hair going to gray and coiled in a bun. She leaned into the accumulating darkness, irritation on her face. “Is it necessary to make so much noise?” I’ll bayonet you through the brisket, Clantz thought, but he held his tongue, for Orlin MacDonald’s sake and his own. He needed only deliver the salted leg and tell the story of Orly’s death, the wooden box and its contents, a story he’d rehearsed a thousand times in the days since the boy had passed. Then it would be on to business of a different kind. “I am here for Sophie,” Clantz said. “If you could fetch her, I’d appreciate it, as I’ve come a long way.” At that, the woman took a quick, loud breath and put a...

Educational system factors that engage resident physicians in an integrated quality improvement curriculum at a VA hospital: a realist evaluation.

Learning about quality improvement (QI) in resident physician training is often relegated to elective or noncore clinical activities. The authors integrated teaching, learning, and doing QI into the routine clinical work of inpatient internal medicine teams at a Veterans Affairs (VA) hospital. This study describes the design factors that facilitated and inhibited the integration of a QI curriculum-including real QI work-into the routine work of inpatient internal medicine teams. A realist evaluation framework used three data sources: field notes from QI faculty; semistructured interviews with resident physicians; and a group interview with QI faculty and staff. From April 2011 to July 2012, resident physician teams at the White River Junction VA Medical Center used the Model for Improvement for their QI work and analyzed data using statistical process control charts. Three domains affected the delivery of the QI curriculum and engagement of residents in QI work: setting, learner, and teacher. The constant presence of the QI material on a public space in the team workroom was a facilitating mechanism in the setting. Explicit sign-out of QI work to the next resident team formalized the handoff in the learner domain. QI teachers who were respected clinical leaders with QI expertise provided role modeling and local system knowledge. Integrating QI teaching into the routine clinical and educational systems of an inpatient service is challenging. Identifiable, concrete strategies in the setting, learner, and teacher domains helped integrate QI into the clinical and educational systems.

Review of Slow Democracy: Rediscovering Community, Bringing Decision Making Back Home by Susan Clark and Woden Teachout (White River Junction, VT: Chelsea Green Publishing, 2012)

Review of Slow Democracy: Rediscovering Community, Bringing Decision Making Back Home by Susan Clark and Woden Teachout (White River Junction, VT: Chelsea Green Publishing, 2012).