Effect of a computerized decision support system on the treatment approach of stage III or IV pressure injury in patients with spinal cord injury: a feasibility study.

BACKGROUND: Stage III and IV pressure injuries (PIs) in patients with spinal cord injury (SCI) require complex interdisciplinary and interprofessional treatment approaches that are difficult to implement. Practical aspects, such as information exchange and coordination, remain challenging. We investigated whether a computerized decision support system (CDSS) could increase treatment adherence and improve clinical outcomes and interprofessional collaboration. METHOD: In this feasibility study, a core team developed the initial treatment process and adapted it based on several discussions with clinical experts and information technologists. The CDSS followed the Basel Decubitus Approach and was used in a clinic specializing in SCI. Thirty patients with SCI admitted for stage III/IV PI between July 2016 and May 2017 were randomly allocated to standard or CDSS-supported care. Between-group differences in treatment adherence, complication rates, length of stay, and costs were analyzed using descriptive statistics. The use of the CDSS and potential barriers and facilitators were evaluated through interprofessional focus groups, transcribed verbatim, and thematically analyzed (30 participants). RESULTS: No differences in SCI characteristics, comorbidities, or PI characteristics (localization: ischium [number (n) = 19 PI, 63%], sacrum [n = 10 PI, 33%], recurrent PI [n = 21, 70%]) were found between the two groups. Furthermore, no statistically significant differences were observed in treatment adherence, frequency of major (20% vs. 13% between CDSS and control group) and minor (33% vs 27%) complications, and length of stay (98 [±28] vs 81 [±23] days). Healthcare professionals found the CDSS to be helpful for visualizing the treatment process. However, the high workload and difficulties in the information technology processes, such as missing reminders, slow computer performance and data processing, and poor accessibility, hindered the effective implementation of the CDSS. CONCLUSION: The implementation of the CDSS to support the treatment of stage III/IV PI in patients with SCI was feasible and included definitions of milestones, interventions, and outcomes. However, to assess the impact of the CDSS, a longer observation period is required. Further, the technical difficulties must be addressed, and solid integration of the CDSS into the clinical information system is necessary. TRIAL REGISTRATION: This quality improvement project received a declaration of no objection from the Ethics Committee of Northwest and Central Switzerland (EKNZ UBE-16/003), and ethical approval was received for the focus groups (EKNZ Req-2017-00860).

Informing Nature-based Climate Solutions for the United States with the best-available science.

Nature-based Climate Solutions (NbCS) are managed alterations to ecosystems designed to increase carbon sequestration or reduce greenhouse gas emissions. While they have growing public and private support, the realizable benefits and unintended consequences of NbCS are not well understood. At regional scales where policy decisions are often made, NbCS benefits are estimated from soil and tree survey data that can miss important carbon sources and sinks within an ecosystem, and do not reveal the biophysical impacts of NbCS for local water and energy cycles. The only direct observations of ecosystem-scale carbon fluxes, for example, by eddy covariance flux towers, have not yet been systematically assessed for what they can tell us about NbCS potentials, and state-of-the-art remote sensing products and land-surface models are not yet being widely used to inform NbCS policymaking or implementation. As a result, there is a critical mismatch between the point- and tree-scale data most often used to assess NbCS benefits and impacts, the ecosystem and landscape scales where NbCS projects are implemented, and the regional to continental scales most relevant to policymaking. Here, we propose a research agenda to confront these gaps using data and tools that have long been used to understand the mechanisms driving ecosystem carbon and energy cycling, but have not yet been widely applied to NbCS. We outline steps for creating robust NbCS assessments at both local to regional scales that are informed by ecosystem-scale observations, and which consider concurrent biophysical impacts, future climate feedbacks, and the need for equitable and inclusive NbCS implementation strategies. We contend that these research goals can largely be accomplished by shifting the scales at which pre-existing tools are applied and blended together, although we also highlight some opportunities for more radical shifts in approach.

Toward understanding the contribution of waterbodies to the methane emissions of a permafrost landscape on a regional scale-A case study from the Mackenzie Delta, Canada.

Waterbodies in the arctic permafrost zone are considered a major source of the greenhouse gas methane (CH4 ) in addition to CH4 emissions from arctic wetlands. However, the spatio-temporal variability of CH4 fluxes from waterbodies complicates spatial extrapolation of CH4 measurements from single waterbodies. Therefore, their contribution to the CH4 budget of the arctic permafrost zone is not yet well understood. Using the example of two study areas of 1,000 km² each in the Mackenzie Delta, Canada, we approach this issue (i) by analyzing correlations on the landscape scale between numerous waterbodies and CH4 fluxes and (ii) by analyzing the influence of the spatial resolution of CH4 flux data on the detected relationships. A CH4 flux map with a resolution of 100 m was derived from two aircraft eddy-covariance campaigns in the summers of 2012 and 2013. We combined the CH4 flux map with high spatial resolution (2.5 m) waterbody maps from the Permafrost Region Pond and Lake Database and classified the waterbody depth based on Sentinel-1 SAR backscatter data. Subsequently, we reduced the resolution of the CH4 flux map to analyze if different spatial resolutions of CH4 flux data affected the detectability of relationships between waterbody coverage, number, depth, or size and the CH4 flux. We did not find consistent correlations between waterbody characteristics and the CH4 flux in the two study areas across the different resolutions. Our results indicate that waterbodies in permafrost landscapes, even if they seem to be emission hot spots on an individual basis or contain zones of above average emissions, do currently not necessarily translate into significant CH4 emission hot spots on a regional scale, but their role might change in a warmer climate.

VOC emission rates over London and South East England obtained by airborne eddy covariance.

Volatile organic compounds (VOCs) originate from a variety of sources, and play an intrinsic role in influencing air quality. Some VOCs, including benzene, are carcinogens and so directly affect human health, while others, such as isoprene, are very reactive in the atmosphere and play an important role in the formation of secondary pollutants such as ozone and particles. Here we report spatially-resolved measurements of the surface-to-atmosphere fluxes of VOCs across London and SE England made in 2013 and 2014. High-frequency 3-D wind velocities and VOC volume mixing ratios (made by proton transfer reaction - mass spectrometry) were obtained from a low-flying aircraft and used to calculate fluxes using the technique of eddy covariance. A footprint model was then used to quantify the flux contribution from the ground surface at spatial resolution of 100 m, averaged to 1 km. Measured fluxes of benzene over Greater London showed positive agreement with the UK's National Atmospheric Emissions Inventory, with the highest fluxes originating from central London. Comparison of MTBE and toluene fluxes suggest that petroleum evaporation is an important emission source of toluene in central London. Outside London, increased isoprene emissions were observed over wooded areas, at rates greater than those predicted by a UK regional application of the European Monitoring and Evaluation Programme model (EMEP4UK). This work demonstrates the applicability of the airborne eddy covariance method to the determination of anthropogenic and biogenic VOC fluxes and the possibility of validating emission inventories through measurements.

Spatially resolved flux measurements of NOx from London suggest significantly higher emissions than predicted by inventories.

To date, direct validation of city-wide emissions inventories for air pollutants has been difficult or impossible. However, recent technological innovations now allow direct measurement of pollutant fluxes from cities, for comparison with emissions inventories, which are themselves commonly used for prediction of current and future air quality and to help guide abatement strategies. Fluxes of NOx were measured using the eddy-covariance technique from an aircraft flying at low altitude over London. The highest fluxes were observed over central London, with lower fluxes measured in suburban areas. A footprint model was used to estimate the spatial area from which the measured emissions occurred. This allowed comparison of the flux measurements to the UK's National Atmospheric Emissions Inventory (NAEI) for NOx, with scaling factors used to account for the actual time of day, day of week and month of year of the measurement. The comparison suggests significant underestimation of NOx emissions in London by the NAEI, mainly due to its under-representation of real world road traffic emissions. A comparison was also carried out with an enhanced version of the inventory using real world driving emission factors and road measurement data taken from the London Atmospheric Emissions Inventory (LAEI). The measurement to inventory agreement was substantially improved using the enhanced version, showing the importance of fully accounting for road traffic, which is the dominant NOx emission source in London. In central London there was still an underestimation by the inventory of 30-40% compared with flux measurements, suggesting significant improvements are still required in the NOx emissions inventory.

Utilization and features of rehabilitation and health services for persons with spinal cord injury.

BACKGROUND: The increasing prevalence of individuals experiencing disabilities underscores the importance of rehabilitation. Nevertheless, healthcare systems are already facing financial constraints, which makes it imperative to strive for a more efficient delivery of services. The first step, however, is to understand how the provision of services behaves for patients with different characteristics. AIM: To determine the most frequently used healthcare services in the (sub)acute phase of rehabilitation of patients with spinal cord injury/disease (SCI/D) and the link with patient characteristics. DESIGN: Observational cohort study. POPULATION: This study analyzes the clinical data of patients discharged from a specialized SCI hospital and rehabilitation center in Switzerland. METHODS: We implemented a compound risk model to estimate the total amount of healthcare services used, defined by length of stay (LOS) and the units per day of health services (sub)acute phase of rehabilitation. RESULTS: The study included 403 individuals with SCI/D. The analysis of the intensity and severity of healthcare services across different patient and injury characteristics revealed differences in the intensity of healthcare use and variations in the length of stay (LOS). Male patients with a low SCIM upon admission tended to use healthcare services more extensively than female patients. In terms of etiology, therapies were employed more intensively for patients with traumatic SCI (TSCI). In addition, the analysis revealed that variations in the intensity of healthcare services used were more significant than those adjusted for LOS. Ultimately, similar patient groups received comparable quantities of healthcare services at the end of treatment. CONCLUSIONS: This population-based study provides information for a better understanding of the determinants of health service use during the (sub)acute rehabilitation phase of individuals with SCI/D. When analyzing LOS, intensity, and severity of services, it shows that the use of healthcare services significantly differs for the level of SCIM at admission, age groups, sex, and etiology. However, the variation among individual patients also suggests the presence of other influential modifiers that were not considered in this analysis. CLINICAL REHABILITATION IMPACT: The approach outlined enables a systematic follow-up of this data analysis by enriching the computed data with additional details about the patient, the patient's treatment, and outcomes.

Characterizing the Services of a Rehabilitation Centre Specialized in Spinal Cord Injury/Disorder using the International Classification of Service Organization in Rehabilitation 2.0 and Implications for Health Reporting: A Demonstration Project.

OBJECTIVES: To characterize the services of a rehabilitation centre specialized in spinal cord injury/disorder (SCI/D) using the International Classification of Service Organization in Rehabilitation (ICSO-R) 2.0, and to evaluate its potential use in meeting health reporting and certification requirements. METHODS: The post-acute and outpatient rehabilitation services at this specialized SCI/D centre were described, the SCI/D Framework of rehabilitation service type definitions considered, various rehabilitation centre stakeholders were consulted, and data were collected using the centre's digital quality management system and institutional management tool. A structured internet search identified the national health reporting and certification systems relevant for SCI/D rehabilitation. The resulting systems were subsequently mapped with ICSO-R 2.0 categories. RESULTS: ICSO-R 2.0 categories pertaining to the provider dimension were generally the same across the post-acute and outpatient services. ICSO-R 2.0 highlighted the nuances in service delivery between these 2 service types. Most of the categories could be mapped to at least 1 of the 10 health reporting and certification systems detected in the website search. CONCLUSION: ICSO-R 2.0 can be used to comprehensively describe the rehabilitation services of a specialized SCI/D centre in Switzerland. Despite some challenges, ISCO-R 2.0 has the potential to facilitate national health reporting and certification.

Vegetation type is an important predictor of the arctic summer land surface energy budget.

Despite the importance of high-latitude surface energy budgets (SEBs) for land-climate interactions in the rapidly changing Arctic, uncertainties in their prediction persist. Here, we harmonize SEB observations across a network of vegetated and glaciated sites at circumpolar scale (1994-2021). Our variance-partitioning analysis identifies vegetation type as an important predictor for SEB-components during Arctic summer (June-August), compared to other SEB-drivers including climate, latitude and permafrost characteristics. Differences among vegetation types can be of similar magnitude as between vegetation and glacier surfaces and are especially high for summer sensible and latent heat fluxes. The timing of SEB-flux summer-regimes (when daily mean values exceed 0 Wm-2) relative to snow-free and -onset dates varies substantially depending on vegetation type, implying vegetation controls on snow-cover and SEB-flux seasonality. Our results indicate complex shifts in surface energy fluxes with land-cover transitions and a lengthening summer season, and highlight the potential for improving future Earth system models via a refined representation of Arctic vegetation types.

Correction: Treatment and cost of pressure injury stage III or IV in four patients with spinal cord injury: the Basel Decubitus Concept.

[This corrects the article DOI: 10.1038/s41394-019-0173-0.].

Treatment and cost of pressure injury stage III or IV in four patients with spinal cord injury: the Basel Decubitus Concept.

Study design: Retrospective chart analyses as part of a quality improvement project. Objectives: To demonstrate treatment of pressure injury (PI) in patients with spinal cord injuries (SCI) and analyse costs using the "modified Basel Decubitus Concept". Setting: Inpatient setting of a specialised acute care and rehabilitation clinic for SCI. Methods: Complex treatment courses of four patients with chronic SCI and PI stage III or IV were described and costs were recorded. The total healthcare services' costs per patient and different profession's involvement were analysed in relation to patient characteristics, treatment phases and milestones demonstrated. Results: The treatment of PI stage III and IV in patients with SCI included input from plastic surgery, rehabilitation medicine, nursing and other involved professions. Recommended interventions were chosen according to the "modified Basel Decubitus Concept". The cost course of PI treatment in patients with SCI depicted the multimodal treatment concept, including three clinically and financially relevant milestones (debridement, flap surgery and mobilisation to wheelchair) as well as the highest costs in the functionally highly dependent patient. Acute care and rehabilitation overlapped with different intensities during the whole treatment process. Conclusion: Multimodal treatment concepts connecting acute and rehabilitation care were applied in these complex health conditions. Cost-explication models including treatment phases and milestones helped to understand resources more easily and integrate aspects of process-based management and quality of care. Scientific evidence is needed to create a recommended quality standard in line with adequate financing of this health condition.

Strong geologic methane emissions from discontinuous terrestrial permafrost in the Mackenzie Delta, Canada.

Arctic permafrost caps vast amounts of old, geologic methane (CH4) in subsurface reservoirs. Thawing permafrost opens pathways for this CH4 to migrate to the surface. However, the occurrence of geologic emissions and their contribution to the CH4 budget in addition to recent, biogenic CH4 is uncertain. Here we present a high-resolution (100 m × 100 m) regional (10,000 km²) CH4 flux map of the Mackenzie Delta, Canada, based on airborne CH4 flux data from July 2012 and 2013. We identify strong, likely geologic emissions solely where the permafrost is discontinuous. These peaks are 13 times larger than typical biogenic emissions. Whereas microbial CH4 production largely depends on recent air and soil temperature, geologic CH4 was produced over millions of years and can be released year-round provided open pathways exist. Therefore, even though they only occur on about 1% of the area, geologic hotspots contribute 17% to the annual CH4 emission estimate of our study area. We suggest that this share may increase if ongoing permafrost thaw opens new pathways. We conclude that, due to permafrost thaw, hydrocarbon-rich areas, prevalent in the Arctic, may see increased emission of geologic CH4 in the future, in addition to enhanced microbial CH4 production.

Inpatient migration patterns in persons with spinal cord injury: A registry study with hospital discharge data.

This study investigated and compared patient migration patterns of persons with spinal cord injury, the general population and persons with morbid obesity, rheumatic conditions and bowel disease, for secondary health conditions, across administrative boundaries in Switzerland. The effects of patient characteristics and health conditions on visiting hospitals outside the residential canton were examined using complete, nationwide, inpatient health records for the years 2010 and 2011. Patients with spinal cord injury were more likely to obtain treatment outside their residential canton as compared to all other conditions. Facilitators of patient migration in persons with spinal cord injury and the general hospital population were private or accidental health insurances covering costs. Barriers of patient migration in persons with spinal cord injury were old age, severe multimorbidity, financial coverage by basic health insurance, and minority language region.

A transparent and transferable framework for tracking quality information in large datasets.

The ability to evaluate the validity of data is essential to any investigation, and manual "eyes on" assessments of data quality have dominated in the past. Yet, as the size of collected data continues to increase, so does the effort required to assess their quality. This challenge is of particular concern for networks that automate their data collection, and has resulted in the automation of many quality assurance and quality control analyses. Unfortunately, the interpretation of the resulting data quality flags can become quite challenging with large data sets. We have developed a framework to summarize data quality information and facilitate interpretation by the user. Our framework consists of first compiling data quality information and then presenting it through 2 separate mechanisms; a quality report and a quality summary. The quality report presents the results of specific quality analyses as they relate to individual observations, while the quality summary takes a spatial or temporal aggregate of each quality analysis and provides a summary of the results. Included in the quality summary is a final quality flag, which further condenses data quality information to assess whether a data product is valid or not. This framework has the added flexibility to allow "eyes on" information on data quality to be incorporated for many data types. Furthermore, this framework can aid problem tracking and resolution, should sensor or system malfunctions arise.