Contribution of emissions from the oil sands activities in Alberta, Canada to atmospheric concentration and deposition of nitrogen and sulfur species at a downwind site.

Oil sands activities in the Athabasca Oil Sands Region in Alberta, Canada, are large sources of atmospheric NOx and SO2. This study investigated the impact of oil sands emissions on the atmospheric deposition of nitrogen and sulfur species at a downwind site, about 350 km from the oil sands facilities. Measurement data are from the Canadian Air and Precipitation Monitoring Network (CAPMoN) from 2015 to 2019, including ambient concentrations of HNO3, pNO3-, NO2, pNH4+, NH3, SO2, pSO42- and base cations, as well as concentrations of NO3-, SO42-, NH4+, and base cations in precipitation. Sector analysis of air mass back trajectories was conducted to distinguish measurements with different air mass origins. Median atmospheric concentrations and dry deposition fluxes of HNO3, pNO3-, NO2, pNH4+, pSO42-, and SO2 on days when the air masses came from the oil sands sector were significantly greater than those with the "Clean" sector by 34-67%, whereas the difference in NH3 concentration was not significant. Contributions of the oil sands emissions to dry deposition fluxes of these species ranged from 3.8 to 13.1%. The precipitation-weighted mean concentrations of NO3-, SO42-, and NH4+ in samples with the oil sands sector were 76 %, 65 % and 81 % greater than those with the "Clean" sector, respectively. Contributions of the oil sands emissions to wet deposition of NO3-, SO42-, and NH4+ were 12.5 ± 8.9 %, 8.7 ± 4.4 %, and 6.0 ± 3.3 %, respectively. The annual total deposition of nitrogen and sulfur were 1.9 kg-N ha-1 and 0.74 kg-S ha-1, respectively, of which 8.0 ± 3.5 % and 8.7 ± 3.6 % were from oil sands emissions. The total deposition of sulfur and nitrogen did not exceed the critical loads (CL) of acidity, but nitrogen deposition exceeded the CLs of nutrient nitrogen in the region.

Evolving assessment pathways for precision oncology medicines to improve patient access: a tumor-agnostic lens.

BACKGROUND: Genomic and molecular alterations are increasingly important in cancer diagnosis, and scientific advances are opening new treatment avenues. Precision oncology (PO) uses a patient's genomic profile to determine optimal treatment, promising fewer side effects and higher success rates. Within PO, tumor-agnostic (TA) therapies target genomic alterations irrespective of tumor location. However, traditional value frameworks and approval pathways pose challenges which may limit patient access to PO therapies. OBJECTIVES: This study describes challenges in assessing PO and TA medicines, explores possible solutions, and provides actionable recommendations to facilitate an iterative life-cycle assessment of these medicines. METHODS: After reviewing the published literature, we obtained insights from key stakeholders and European experts across a range of disciplines, through individual interviews and an industry workshop. The research was guided and refined by an international expert committee through 2 sounding board meetings. RESULTS: The current challenges faced by PO and TA medicines are multiple and can be demonstrated through real-world examples of the current barriers and opportunities. A life-cycle approach to assessment should be taken, including key actions at the early stages of evidence generation, regulatory and reimbursement stage, as well as payment and adoption solutions that make use of the evolving evidence base. Working toward these solutions to maximize PO medicine value is a shared responsibility and stands to benefit all stakeholders. CONCLUSIONS: Our call to action is to expand access to comprehensive genomic testing, foster a learning health care system, enable fast and equitable access to cost-effective treatments, and ultimately improve health outcomes.

People get ready! A new generation of Alzheimer's therapies may require new ways to deliver and pay for healthcare.

The development of disease-modifying therapies (DMTs) for Alzheimer's disease (AD) has progressed over the last decade, and the first-ever therapies with potential to slow the progression of disease are approved in the United States. AD DMTs could provide life-changing opportunities for people living with this disease, as well as for their caregivers. They could also ease some of the immense societal and economic burden of dementia. However, AD DMTs also come with major challenges due to the large unmet medical need, high prevalence of AD, new costs related to diagnosis, treatment and monitoring, and uncertainty in the therapies' actual clinical value. This perspective article discusses, from the broad perspective of various health systems and stakeholders, how we can overcome these challenges and improve society's readiness for AD DMTs. We propose that innovative payment models such as performance-based payments, in combination with learning healthcare systems, could be the way forward to enable timely patient access to treatments, improve accuracy of cost-effectiveness evaluations and overcome budgetary barriers. Other important considerations include the need for identification of key drivers of patient value, the relevance of different economic perspectives (i.e. healthcare vs. societal) and ethical questions in terms of treatment eligibility criteria.

Inter-comparison of measurements of inorganic chemical components in precipitation from NADP and CAPMoN at collocated sites in the USA and Canada during 1986-2019.

Wet deposition monitoring is a critical part of the long-term monitoring of acid deposition, which aims to assess the ecological impact of anthropogenic emissions of SO2 and NOx. In North America, long-term wet deposition has been monitored through two national networks: the Canadian Air and Precipitation Monitoring Network (CAPMoN) and the US National Atmospheric Deposition Program (NADP), for Canada and the USA, respectively. In order to assess the comparability of measurements from the two networks, collocated measurements have been made at two sites, one in each country, since 1986 (Sirois et al., in Environmental Monitoring and Assessment, 62, 273-303, 2000; Wetherbee et al., in Environmental Monitoring and Assessment, 1995-2004, 2010). In this study, we compared the measurements from NADP and CAPMoN instrumentation at the collocated sites at the Pennsylvania State University (Penn State), USA, from 1989 to 2016, and Frelighsburg, Quebec, Canada, from 2002 to 2019. We also included in the study the collocated daily-vs-weekly measurements by the CAPMoN network during 1999-2001 and 2016-2017 in order to evaluate the differences in wet concentration of ions due to sampling frequency alone. The study serves as an extension to two previous CAPMoN-NADP inter-comparisons by Sirois et al. (Environmental Monitoring and Assessment, 62, 273-303, 2000) and Wetherbee et al., in (Environmental Monitoring and Assessment, 1995-2004, 2010). At the Penn State University site, for 1986-2019, CAPMoN was higher than NADP for all ions, in terms of weekly concentration, precipitation-weighted annual mean concentration, and annual wet deposition. The precipitation-weighted annual mean concentrations were higher for SO42- (2%), NO3- (12%), NH4+ (16%), H+ (6%), and base cations and Cl- (11-15%). For annual wet deposition, CAPMoN was higher for SO4-2, NO3-, NH4+ and H+ (5-17%), and base cations and Cl- (12-17%) during 1986-2019. At the Frelighsburg site, NADP changed the sample collector in October 2011. For 2002-2011, the relative differences at the Frelighsburg site were positive and similar in magnitude to those at the Penn State site. For 2012-2019, the precipitation-weighted annual mean concentrations were 5-27% lower than NADP, except for H+, which was 23% higher. The change in sample collector by NADP had the largest effect on between-network biases. The comparisons of daily-vs-weekly measurements conducted by the CAPMoN network during 1999-2001 and 2016-2017 show that the weekly measurements were higher than the daily measurements by 1-3% for SO42-, NO3-, and NH4+; 3-9% for Ca2+, Mg2+, Na+, and Cl-; 10-24% for K+; and lower for H+ by 8-30% in terms of precipitation-weighted mean concentration. Thus, differences in sampling frequencies did not contribute to the systematically higher CAPMoN measurements. Understanding the biases in the data for these networks is important for interpretation of continental scale deposition models and transboundary comparison of wet deposition trends.

Synthetic OCT-A blood vessel maps using fundus images and generative adversarial networks.

Vessel segmentation in fundus images permits understanding retinal diseases and computing image-based biomarkers. However, manual vessel segmentation is a time-consuming process. Optical coherence tomography angiography (OCT-A) allows direct, non-invasive estimation of retinal vessels. Unfortunately, compared to fundus images, OCT-A cameras are more expensive, less portable, and have a reduced field of view. We present an automated strategy relying on generative adversarial networks to create vascular maps from fundus images without training using manual vessel segmentation maps. Further post-processing used for standard en face OCT-A allows obtaining a vessel segmentation map. We compare our approach to state-of-the-art vessel segmentation algorithms trained on manual vessel segmentation maps and vessel segmentations derived from OCT-A. We evaluate them from an automatic vascular segmentation perspective and as vessel density estimators, i.e., the most common imaging biomarker for OCT-A used in studies. Using OCT-A as a training target over manual vessel delineations yields improved vascular maps for the optic disc area and compares to the best-performing vessel segmentation algorithm in the macular region. This technique could reduce the cost and effort incurred when training vessel segmentation algorithms. To incentivize research in this field, we will make the dataset publicly available to the scientific community.

Developing nurse-sensitive outcomes in acute inpatient mental health settings-A systematic review.

BACKGROUND: While nurse-sensitive outcomes (NSOs) are well established in numerous health settings, to date there is no indicator suite of NSOs for inpatient mental health settings. AIM: To assess the relationship between nursing variables and patient outcomes in acute inpatient mental health settings to determine which outcomes can be used as indicators of the quality of nursing care. METHODS: Databases accessed were CINAHL, MEDLINE, PsycINFO and EMBASE, last searched in May 2022. The review followed the 2020 PRISMA checklist for systematic reviews. Papers published between 1995 and 2022, conducted in acute mental health care units were included. The quality of the studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool. A meta-analysis was not possible because of the large number of variables and measurement inconsistencies. RESULTS: A total of 57 studies were reviewed. Studies were categorised according to whether they found a significant or non-significant relationship between nurse variables and patient outcomes. Seven outcomes-aggression, seclusion, restraint, absconding, pro-re-nata medications, special observations and self-harm-were identified. For each outcome, there were significant findings for several nurse variables indicating that all included outcomes could be used as NSOs. However, evidence for aggression, seclusion and restraint use as suitable NSOs was more robust than the evidence for self-harm, absconding, pro-re-nata medications and special observations. CONCLUSION: All the seven outcomes can all be used to develop an NSO indicator suite in mental health inpatient settings. More work is needed to establish high-quality studies to clearly demonstrate the relationship between these outcome measures and changes in nurse variables such as nurse staffing, skill mix, work environment, nurse education and nurse experience. PATIENT AND PUBLIC CONTRIBUTION: Patient or public contribution was not possible because of the type of the variables being explored.

Getting a grip on Safewards: The cross impact of clinical supervision and Safewards model on clinical practice.

The Safewards model is used across various mental health settings to reduce incidents of conflict and containment and its efficacy in reducing the use of seclusion and restraint, improving patients' experiences of care, and enhancing safety within clinical settings is well documented (Bowers, Journal of Psychiatric & Mental Health Nursing, 21, 2014, 499). However, there are barriers to successful implementation, including level of staff buy-in (Baumgardt et al., Frontiers in Psychiatry, 10, 2019, 340; Price et al., Mental Health Practice, 19, 2016, 14). This mixed-method study assessed the impact of adopting a Safewards model within a clinical supervision framework in an approach, named Group Reflective integrated Practice with Safewards (GRiP-S), which integrates Safewards theory within the clinical supervision framework. Both quantitative and qualitative data were collected using the questions derived from the Manchester Clinical Supervision Scale -26© (Winstanley & White, The Wiley International Handbook of Clinical Supervision. John Wiley & Sons Ltd, 2014). A total of 67 surveys and eight interviews were completed by nursing staff. Overall, the results showed that the GRiP-S approach improves the implementation of Safewards and nurses' clinical practice. Nursing staff satisfaction with clinical supervision and Safewards improved post GRiP-S pre-GRIP-S- 69.54 (SD 16.059); post-GRIP-S 71.47 (SD 13.978). The survey also identified nursing staff's perception of GRiP-S in the restorative and formative domains of clinical supervision improved. The restorative mean score pre-GRiP-S was 28.43 (SD 5.988) and post-GRiP-S 29.29 (SD 3.951). The formative mean score pre-GRiP-S was 20.10 (SD 5.617) and post-GRiP-S 20.63 (SD 13.978). The qualitative results further explained the satisfaction levels and the changes seen in perception domains. The GRiP-S approach reported (i) improved therapeutic relationships and patient centred care, (ii) improved staff communication and teamwork, (iii) barriers to GRiP-S engagement, and (iv) assistance with the change process. The results indicate that the GRiP-S approach had a positive impact on Safewards delivery and supports ongoing change of practice.

Inpatient Teleneurology Follow-up Has Comparable Outcomes to In-Person Neurology Follow-up.

Background and Objectives: Community emergency departments often transfer patients for lack of neurology coverage, potentially burdening patients and accepting facilities. Telestroke improves access to acute stroke care, but there is a lack of data on inpatient teleneurology and telestroke care. Methods: From our prospective telestroke registry, we retrospectively reviewed 3702 consecutive patients who were seen via telestroke between September 2015 and December 2018. Patients who required transfer after initial telestroke evaluation or who were kept at hospitals without consistent neurology coverage were excluded from analysis. We compared baseline demographics, clinical characteristics, and hospital outcomes in patients who were subsequently followed remotely by a teleneurology neurohospitalist and those followed in person by a neurohospitalist. Results: There were 447 (23%) patients followed by a teleneurology neurohospitalist and 1459 (77%) patients followed in person by a neurohospitalist. Both groups presented with similar stroke severity. In multivariate analysis, there were no significant differences in discharge disposition, stroke readmission rates, or 90-day modified Rankin Scale (mRS) scores. Length of stay was shorter with teleneurology follow-up. In the subgroup of patients who received tissue plasminogen activator, patients showed no differences in outcomes and had similar complication rates. Teleneurology follow-up resulted in a 3% transfer rate for higher level of care after admission. There remained no difference in outcomes in a subanalysis without Comprehensive Stroke Centers. A higher proportion of non-Hispanic Black patients and a lower proportion of Hispanic patients in the teleneurology follow-up group were possibly due to spoke location demographics. Discussion: Teleneurology follow-up resulted in comparable outcomes to in-person neurology follow-up, with few transfers after admission. For select neurology and ischemic stroke patients, teleneurology follow-up provides an alternative to transfer for hospitals lacking neurology coverage.

Computed Tomography Angiography Quantification of Intracranial and Extracranial Vascular Narrowing in Ischemic Stroke: Differences Between Patients With and Without Illicit Drug Use.

OBJECTIVE: Previous studies have linked illicit drug consumption and stroke. The purpose of this study is to identify specific imaging findings depicted on computed tomography angiography on patients with illicit drug-associated stroke. METHODS: This is a retrospective case-control study that included ischemic stroke patients. Subjects who tested positive for cocaine or marijuana were considered as cases, while patients who tested negative were included as controls. Matching of the controls was carried out based on the presence of stroke risk factors. A previously validated scale was used to calculate narrowing scores through computed tomography angiography. Comparison between cases and matched controls was evaluated by paired t test for age and body mass index, and by Wilcoxon signed rank test for intracranial, extracranial, and total scores. RESULTS: One hundred seventy-four patients were included in the study, 87 subjects for each group. Because of matching, baseline status differed only on body mass index, with a greater proportion of obese subjects among controls ( P < 0.016). Subgroup analysis demonstrated that it is more likely to find any intracranial abnormality among cocaine consumers when compared with controls ( P = 0.041). CONCLUSIONS: By using computed tomography angiography, we found that stroke patients with history of cocaine consumption had a higher incidence of intracranial circulation narrowing compared with matched controls.

Factors Affecting Citizen Trust and Public Engagement Relating to the Generation and Use of Real-World Evidence in Healthcare.

The potential for the use of real-world data (RWD) to generate real-world evidence (RWE) that can inform clinical decision-making and health policy is increasingly recognized, albeit with hesitancy in some circles. If used appropriately, the rapidly expanding wealth of health data could improve healthcare research, delivery of care, and patient outcomes. However, this depends on two key factors: (1) building structures that increase the confidence and willingness of European Union (EU) citizens to permit the collection and use of their data, and (2) development of EU health policy to support and shape data collection infrastructures, methodologies, transmission, and use. The great potential for use of RWE in healthcare improvement merits careful exploration of the drivers of, and challenges preventing, efficient RWD curation. Literature-based research was performed to identify relevant themes and discussion topics for two sets of expert panels, organized by the European Alliance for Personalised Medicine. These expert panels discussed steps that would enable a gradual but steady growth in the quantity, quality, and beneficial deployment of RWE. Participants were selected to provide insight based on their professional medical, economic, patient, industry, or governmental experience. Here, we propose a framework that addresses public trust and access to data, cross-border governance, alignment of evidence frameworks, and demonstrable improvements in healthcare decisions. We also discuss key case studies that support these recommendations, in accordance with the discussions at the expert panels.

Improving Estimates of Sulfur, Nitrogen, and Ozone Total Deposition through Multi-Model and Measurement-Model Fusion Approaches.

Earth system and environmental impact studies need high quality and up-to-date estimates of atmospheric deposition. This study demonstrates the methodological benefits of multimodel ensemble and measurement-model fusion mapping approaches for atmospheric deposition focusing on 2010, a year for which several studies were conducted. Global model-only deposition assessment can be further improved by integrating new model-measurement techniques, including expanded capabilities of satellite observations of atmospheric composition. We identify research and implementation priorities for timely estimates of deposition globally as implemented by the World Meteorological Organization.

Non-contrast head CT-based thrombolysis for wake-up/unknown onset stroke is safe: A single-center study and meta-analysis.

BACKGROUND: Recent studies have shown that tPA can be safely administered past the standard 4.5 h window with good outcomes when selected with multi-model imaging, which is often lacking outside of comprehensive stroke centers. AIM: We aim to analyze the safety and outcomes of wake up/unknown onset (WUS/UNK) patients treated based on non-contrast head CT (NCCT) at our institution and in the literature. METHODS: Suspected stroke patients from January 2015 to December 2018 receiving tPA within 4.5 h (standard window-SW) and with WUS/UNK based on NCCT and clinical-imaging mismatch were identified. We compared baseline characteristics, tPA metrics, and outcome data, with primary outcome as symptomatic intracerebral hemorrhage (sICH). A meta-analysis was performed evaluating NCCT-based treatment of WUS/UNK patients. RESULTS: Of 1827 patients treated at our hub or through telestroke, 93 underwent WUS/UNK-based treatment. There was no statistical difference in sICH between WUS/UNK and SW: 1% vs. 4% (OR 0.3; 95% confidence interval 0.0-1.9). 90-day modified Rankin scale outcomes were similar between SW and WUS/UNK-treated patients. Seven studies encompassing 485 WUS/UNK patients were included in a pooled analysis with a 2.1% incidence of sICH. In our meta-analysis, three studies compared NCCT-based treated WUS/UNK patients with SW patients with no difference in rate of hemorrhage: 2.1% vs 3.4% (OR 1.01; 95% confidence interval 0.45-2.28). INTERPRETATION: Our single-center analysis and meta-analysis suggest that tPA can be safely administered based on NCCT with comparable rates of sICH for select WUS/UNK stroke patients.

Comparing Aerobic Exercise with Yoga in Anxiety Reduction: An Integrative Review.

Anxiety is a common mental health disorder that affects many Americans yet often goes unrecognized or undertreated. The purpose of this article is to review the current literature to assist in determining which alternative and complimentary therapy, aerobic exercise or yoga, is most beneficial in reducing anxiety symptoms. The literature search process resulted in a total of 14 articles included in the review. Results indicate that yoga is more effective in decreasing anxiety symptoms than aerobic exercise. Health care providers can use this information to help recommend an alternative form of therapy for patients.

Digital cognitive behavioural therapy for insomnia and primary care costs in England: an interrupted time series analysis.

BACKGROUND: Sleepio is an automated digital program that delivers digital cognitive behavioural therapy for insomnia (dCBT-I). Sleepio has been proven effective in improving sleep difficulties; however, evidence for the possible impact of Sleepio use on healthcare costs in the UK has not, to the authors' knowledge, previously been developed. AIM: To identify the effect of a population-wide rollout of Sleepio in terms of primary care costs in the NHS in England. DESIGN & SETTING: The study was conducted in the Thames Valley region of England, where access to Sleepio was made freely available to all residents between October 2018 and January 2020. The study relies on a quasi-experimental design, using an interrupted time series (ITS) to compare the trend in primary care costs before and after the rollout of Sleepio. METHOD: Primary care data for people with relevant characteristics from nine general practices in Buckinghamshire was used. Primary care costs include general practice contacts and prescriptions. Segmented regression analysis was used to estimate primary and secondary outcomes. RESULTS: For the 10 705 patients included in the sample, the total saving over the 65-week follow-up period was £71 027. This corresponds to £6.64 per person in the sample or around £70.44 per Sleepio user. Secondary analyses suggest that savings may be driven primarily by reductions in prescribing. CONCLUSION: Sleepio rollout reduced primary care costs. National adoption of Sleepio may reduce primary care costs by £20 million in the first year. The expected impact on primary care costs in any particular setting will depend on the uptake of Sleepio.