Sedimentary record of microplastics in coastal wetland, eastern China.

Microplastic (MP) dynamics can reflect history of plastic production and waste management in nearby areas. However, the stratigraphy of MPs in coastal wetlands and their link to policy and economic pattern changes are currently unclear. Here, MP stratigraphic records in sediment core from coastal wetlands in Yancheng, China, were used to reconstruct plastic pollution history. Neural network models simulated how policy intervention and economic development affected MP accumulation over time. We showed that MP abundance curves with boundaries from 1920 to 2019 had four stages. MP growth slowed or even decreased in the mid-to-late 1980s due to improved waste management and wastewater treatment since the late 1980s. Human activities were the primary factor affecting MP abundance and shape, followed by sediment properties. We predict that the environmental impact of MPs will continue to increase in the next decade. Current plastic policy measures focus on predictable waste emissions, but hidden sources like clothing fibers and tire wear that significantly contribute to MP pollution require further attention.

Scenario analysis of phosphorus flow in food production and consumption system in the Mwanza region, Tanzania.

Since the mineral, phosphorus (P), has dual properties of being limited resources for use, and being a pollutant for studying sustainable management of anthropogenic P flows in wetlands and soils, currently P receives the highest interests among researchers around the world. This study has successfully mapped P flows for a reference year (2017) and a future year (2030) using different scenarios of food production and consumption system (hereafter 'system') in the Mwanza region (Tanzania). The results showed that the total P input and output for 2017 alone were 9770 t and 7989 t, respectively. However, as high as 1781 tP accumulated in the system and the potentially recyclable P found, is yet to be recovered due to economic reasons and the lack of market. The main anthropogenic P input to the system occurred via imported feed, fertilizer, and crop food, accounting for about 99.72 % of the total input flow. The output was comprised of animal products exported with 3428 tP, and various P-contained wastes which were lost to water bodies with 4561tP. Analysis of the 2030 scenario showed that setting P management objectives from different perspectives such as the total P budget balance, potential recyclable P, and P emission, can help develop differentially preferred management strategies and measures in the Mwanza region. The combination of diet change, precision feeding, and integrated waste management practices presents the best prospects for decreasing P budget and losses, and the amount of P that can be potentially recovered from the system. We propose a package of integrated P management measures for the Mwanza region. Given the similarity of regional socio-economic development background around the Lake Victoria basin, the model can be used to guide the study of anthropogenic P flow analysis in other areas along the shore of Lake Victoria (Africa).

Reactive nitrogen budgets in human-nature coupling system in lakeside area with insufficient data - A case study of Mwanza, Tanzania.

Nitrogen (N) is an essential nutrient element for life, and also a major element involved in the composition of greenhouse gases, surface water pollutants, air pollutants, etc. Quantifying and evaluating the nitrogen budget of a region is very important for effectively controlling the nitrogen discharge and scientifically managing the nitrogen cycle. In this paper, the urban Rural Complex N Cycling (URCNC) model was used to analyze the nitrogen budget of Mwanza region, a typical lakeside area with insufficient data, and the nitrogen flow process of livestock subsystem, cropland subsystem, human subsystem and landfill subsystem was clearly described and the nitrogen input sources of atmospheric subsystem and surface water subsystem were clarified. And the results demonstrated: (1) the cropland subsystem was the subsystem with the largest nitrogen flux, and the input, output and accumulation of nitrogen were 33,116 t of N, 31,925 t of N and 1191 t of N, respectively. Livestock subsystem was the second largest subsystem of nitrogen flux, and the input, output and accumulation of nitrogen were 31,013 t, 30,183 t and 830 t, respectively. The nitrogen flux of the human subsystem was also large, and the nitrogen input, output and accumulation were 17,905, 17,125 and 780 t, respectively. The nitrogen input, output and accumulation of the landfill subsystem were 3700 t, 770 t and 2930 t, respectively. (2) 8093 t of N, 6864 t of N, 3959 t of N, and 758 t of N emitted into the atmospheric subsystem from the livestock subsystem, cropland subsystem, human subsystem, and landfill subsystem, respectively. (3) The total Nr input of surface water subsystem increased from 18,545 t of N in 2010 to 20,174 t of N in 2020, with an increase of 8.78 % in the past decade. It was estimated that by 2030, the total Nr input of the surface water subsystem would reach 24,946 t of N with an increase of 23.65 % compared with 2020. The livestock subsystem was the largest source, the cropland subsystem was the second largest source and human subsystem was an important source. (4) Population growth, economic development and urbanization are the main nitrogen driving factor. (5) Technology and policy together have important contributions to the reduction of nitrogen pollution in surface water.

Assessment of urban river water pollution with urbanization in East Africa.

Anthropogenic pollution plays an important part in deteriorating the water quality of rivers all over the world, especially in urban areas of Africa where water quality monitoring is still seriously constrained by the limited test facility and capability. In this study, for evaluating the impact of urbanization on the river water quality, we investigated four typical urban rivers of Tanzania through the upper-urban-down gradient assessment approach and analyzed by water quality index (WQI) and statistical methods. The physicochemical indices monitored in these rivers revealed that the contents of those indicators of TN, TP, PO43-, NH4+, CODMn, and NO3- were accumulated significantly in the lower reaches of the cities, which indicated the life-type pollution characteristics in such urban rivers of Africa. The following main conclusions are achieved from this study. The water quality of 30% of the investigated river sections is in the medium to good status based on the subjective WQI with sensory factors included. Moreover, the sections with obvious water quality decline are mainly limited to the river segments within the urban central area, and severe pollution of water bodies is closely related to large cities, indicating an increasing pollution tendency with the quickly growing population. Therefore, to help formulate water pollution control policies in response to the rapid urban expansion in African countries, it is necessary to adopt an economical and feasible method to carry out early monitoring of surface water quality timely.

Down to the Last Dollar: Utilizing a Virtual Budgeting Exercise to Recognize Implicit Bias.

INTRODUCTION: As social determinants of health and implicit bias are recognized as critical components of medical education, there is a need for novel approaches beyond didactics. We developed a small-group budgeting exercise to simulate the impact of poverty. Pediatrics exemplifies the effects of poverty on the family. This exercise allowed students to recognize the effects of food insecurities on health and reflect on biases regarding patients living in poverty. METHODS: The virtual interactive budgeting exercise (1.5-2 hours) introduced third-year pediatric clerkship students to the challenges faced by a single parent living in poverty, requiring them to make choices on which budget items were most important. Students attempted to balance budgets within small breakout groups, followed by a group reflection on biases encountered. A faculty facilitator then debriefed with the larger group. RESULTS: Within the first four rotations of the 2020-2021 academic year, 75 students completed the budgeting exercise and reflection, with 61 students completing the postexercise survey evaluation. Between 94% and 98% rated the objectives as met to a moderate, considerable, or very high degree. In addition, 98% of students noted the group discussion heightened their awareness regarding biases, and 95% agreed or strongly agreed the activity was conducted virtually without difficulty. DISCUSSION: This simulated budgeting exercise provides a well-rounded experience for medical students, that can be administered at either the preclerkship or clerkship level, at a minimal cost, with interactive engagement of students in a virtual environment and reflection on biases within a group context.

Disparities in Mortality from Larynx Cancer: Implications for Reducing Racial Differences.

OBJECTIVE: Race predicts overall mortality (OM) of laryngeal squamous cell carcinoma (LSCC) in the United States (US). We assessed whether racial disparities affect cancer-specific mortality (CSM) using the Surveillance, Epidemiology, and End Results (SEER) database. METHODS: Adults with LSCC from 2004 to 2015 were selected. Univariable and multivariable Cox proportional hazards and Fine-Gray competing-risks regression analysis adjusted for clinicodemographic factors defined hazard ratios (aHR). RESULTS: We identified 14,506 patients. The median age was 63 years. Most were male (11,725, 80.8%) and white (11,653, 80.3%), followed by Black (2294, 15.8%). Most had early-stage disease (7544, 52.0%) and received radiotherapy only (4107, 28.3%), followed by chemoradiation (3748, 25.8%). With median follow-up of 60 months, overall 3- and 5-year OM were 34.0% and 43.2%; CSM were 16.0% and 18.9%, respectively. Black patients had higher OM than white patients on univariable (HR 1.35, 95% CI, 1.26-1.44, P < .001) and multivariable (aHR 1.10, 95% CI, 1.02-1.18, P = .011) analyses. Black patients had higher CSM on univariable analysis (HR 1.22, 95% CI, 1.09-1.35, P < .001) but not on multivariable CSM analysis (aHR 1.01, 95% CI, 0.90-1.13, P = .864). On multivariable analysis, year of diagnosis, age, disease site, stage, treatment, nodal metastasis, marital status, education, and geography significantly predicted CSM. CONCLUSION: On multivariable analyses controlling for sociodemographic, clinical, and treatment characteristics, Black and white patients differed in OM but not in CSM. However, Black patients presented with greater proportions of higher stage cancers and sociodemographic factors such as income and marital status that were associated with worse outcomes. Efforts to target sociodemographic disparities may contribute to the mitigation of racial disparities in LSCC. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1147-E1155, 2021.

Recurrent Respiratory Papillomatosis Office versus Operating Room: Systematic Review and Meta-Analysis.

OBJECTIVES: Recurrent respiratory papillomatosis can be treated in the office or operating room (OR). The choice of treatment is based on several factors, including patient and surgeon preference. However, there is little data to guide the decision-making. This study examines the available literature comparing operative treatment in-office versus OR. METHODS: A systematic review was performed following Preferred Reporting Items for Systematic Reviews guidelines. Of 2,864 articles identified, 78 were reviewed full-length and 18 were included. Outcomes of interest were recurrence and complication rates, number of procedures, time interval between procedures, and cost. RESULTS: Only one study compared outcomes of operative in-office to OR treatments. The weighted average complication rate for OR procedures was 0.02 (95% confidence interval [CI] 0.00-0.32), n = 8, and for office procedures, 0.17 (95% CI 0.08-0.33), n = 6. The weighted average time interval between OR procedures was 10.59 months (5.83, 15.35) and for office procedures 5.40 months (3.26-7.54), n = 1. The weighted average cost of OR procedures was $10,105.22 ($5,622.51-14,587.83), n = 2 versus $2,081.00 ($1,987.64-$2,174.36), n = 1 for office procedures. CONCLUSION: Only one study compares office to OR treatment. The overall data indicate no differences aside from cost and imply that office procedures may be more cost-effective than OR procedures. However, the heterogeneous data limits any strong comparison of outcomes between office and OR-based treatment of laryngeal papillomas. More studies to compare the two treatment settings are warranted.

The relationship of hospital market concentration, costs, and quality for major surgical procedures.

BACKGROUND: Our objective was to determine the association between indicators of surgical quality - incidence of major complications and failure-to-rescue - and hospital market concentration in light of differences in costs of care. METHODS: Patients undergoing coronary artery bypass graft (CABG), colon resection, pancreatic resection, or liver resection in the 2008-2011 Nationwide Inpatient Sample were identified. The effect of hospital market concentration on major complications, failure-to-rescue, and inpatient costs was estimated at the lowest and highest mortality hospitals using multivariable regression techniques. RESULTS: A weighted total of 527,459 patients were identified. Higher market concentration was associated with between 4% and 6% increased odds of failure-to-rescue across all four procedures. Across procedures, more concentrated markets had decreased inpatient costs (average marginal effect ranging from -$3064 (95% CI: -$5812 - -$316) for CABG to -$4876 (-$7773 - -$1980) for liver resection. CONCLUSION: In less competitive (more concentrated) hospital markets, higher overall risk of failure-to-rescue after complications was accompanied by lower inpatient costs, on average. These data suggest that market controls may be leveraged to influence surgical quality and costs.

Assessing the Financial Burden Associated With Treatment Options for Resectable Pancreatic Cancer.

OBJECTIVE: The aim of this study is to assess the financial burden associated with treatment options for resectable pancreatic cancer. BACKGROUND: As the volume of cancer care increases in the United States, there is growing interest among both clinicians and policy-makers to reduce its financial impact on the healthcare system. However, costs relative to the survival benefit for differing treatment modalities used in practice have not been described. METHODS: Patients undergoing resection for pancreatic cancer were identified in the Truven Health MarketScan database. Associations between chemoradiation therapies and survival were performed using parameterized multivariable accelerated failure time models. Median payments over time were calculated for surgery, chemoradiation, and subsequent hospitalizations. RESULTS: A total of 2408 patients were included. Median survival among all patients was 21.1 months [95% confidence interval (CI): 19.8-22.5 months], whereas median follow-up time was 25.1 months (95% CI: 23.5-26.5 months). After controlling for comorbidity, receipt of neoadjuvant therapy, and nodal involvement, a longer survival was associated with undergoing combination gemcitabine and nab-paclitaxel [time ratio (TR) = 1.26, 95% CI: 1.02-1.57, P = 0.035) or capecitabine and radiation (TR = 1.25, 95% CI: 1.04-1.51, P = 0.018). However, median cumulative payments for gemcitabine with nab-paclitaxel were highest overall [median $74,051, interquartile range (IQR): $38,929-$133,603). CONCLUSIONS: Total payments for an episode of care relative to improvement in survival vary significantly by treatment modality. These data can be used to inform management decisions about pursuing further care for pancreatic cancer. Future investigations should seek to refine estimates of the cost-effectiveness of different treatments.

The Effect of Frailty Index on Early Outcomes after Combined Colorectal and Liver Resections.

BACKGROUND: Although previous studies have examined frailty as a potential predictor of adverse surgical outcomes, little is reported on its application. We sought to assess the impact of the 5-item modified frailty index (mFI) on morbidity in patients undergoing combined colorectal and liver resections. METHODS: Adult patients who underwent combined colorectal and liver resections were identified using the ACS-NSQIP database (2005-2015). The 5-item mFI consists of history of chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, and partial/total dependence. Patients were stratified into three groups: mFI 0, 1, or ≥ 2. The impact of the mFI on primary outcomes (30-day overall and serious morbidity) was assessed using multivariable logistic regression. Subgroup analyses by age and hepatectomy type was also performed. RESULTS: A total of 1928 patients were identified: 55.1% with mFI = 0, 33.2% with mFI = 1, and 11.7% with mFI ≥ 2. 75.9% of patients underwent wedge resection/segmentectomy (84.6% colon, 15.4% rectum), and 24.1% underwent hemihepatectomy (88.8% colon, 11.2% rectum). On unadjusted analysis, patients with mFI ≥ 2 had significantly greater rates of overall and serious morbidity, regardless of age and hepatectomy type. These findings were consistent with the multivariable analysis, where patients with mFI ≥ 2 had increased odds of overall morbidity (OR 1.41, 95% CI 1.02-1.96, p = 0.037) and were more than twice likely to experience serious morbidity (OR 2.12, 95% CI 1.47-3.04, p < 0.001). CONCLUSIONS: The 5-item mFI is significantly associated with 30-day morbidity in patients undergoing combined colorectal and liver resections. It is a tool that can guide surgeons preoperatively in assessing morbidity risk in patients undergoing concomitant resections.

Variation in markup of general surgical procedures by hospital market concentration.

BACKGROUND: Increasing hospital market concentration (with concomitantly decreasing hospital market competition) may be associated with rising hospital prices. Hospital markup - the relative increase in price over costs - has been associated with greater hospital market concentration. METHODS: Patients undergoing a cardiothoracic or gastrointestinal procedure in the 2008-2011 Nationwide Inpatient Sample (NIS) were identified and linked to Hospital Market Structure Files. The association between market concentration, hospital markup and hospital for-profit status was assessed using mixed-effects log-linear models. RESULTS: A weighted total of 1,181,936 patients were identified. In highly concentrated markets, private for-profit status was associated with an 80.8% higher markup compared to public/private not-for-profit status (95%CI: +69.5% - +96.9%; p < 0.001). However, private for-profit status in highly concentrated markets was associated with only a 62.9% higher markup compared to public/private not-for-profit status in unconcentrated markets (95%CI: +45.4% - +81.1%; p < 0.001). CONCLUSION: Hospital for-profit status modified the association between hospitals' market concentration and markup. Government and private not-for-profit hospitals employed lower markups in more concentrated markets, whereas private for-profit hospitals employed higher markups in more concentrated markets.

Early Surgical Intervention for Acute Ulcerative Colitis Is Associated with Improved Postoperative Outcomes.

BACKGROUND: Timing of surgical intervention for acute ulcerative colitis has not been fully examined during the modern immunotherapy era. Although early surgical intervention is recommended, historical consensus for "early" ranges widely. The purpose of this study was to evaluate outcomes according to timing of urgent surgery for acute ulcerative colitis. METHODS: All non-elective total colectomies in ulcerative colitis patients were identified in the National Inpatient Sample from 2002 to 2014. Procedures, comorbidities, diagnoses, and in-hospital outcomes were collected using International Classification of Disease, 9th Revision codes. An operation was defined as early if within 24 hours of admission. Results were compared between the early versus delayed surgery groups. RESULTS: We found 69,936 patients that were admitted with ulcerative colitis, and 2650 patients that underwent non-elective total colectomy (3.8%). Early intervention was performed in 20.4% of patients who went to surgery. More early operations were performed laparoscopically (28.1% versus 23.3%, p = 0.021) and on more comorbid patients (Charlson Index, p = 0.008). Median total hospitalization costs were $20,948 with an early operation versus $33,666 with a delayed operation (p < 0.001). Delayed operation was an independent risk for a complication (OR = 1.46, p = 0.001). Increased hospitalization costs in the delayed surgery group were statistically significantly higher with a reported complication (OR = 3.00, p < 0.001) and lengths of stay (OR = 1.26, p < 0.001). CONCLUSION: Delayed operations for acute ulcerative colitis are associated with increased postoperative complications, increased lengths of stay, and increased hospital costs. Further prospective studies could demonstrate that this association leads to improved outcomes with immediate surgical intervention for medically refractory ulcerative colitis.

Association of Hospital Market Concentration With Costs of Complex Hepatopancreaticobiliary Surgery.

IMPORTANCE: Trade-offs involved with market competition, overall costs to payers and consumers, and quality of care have not been well defined. Less competition within any given market may enable provider-driven increases in charges. OBJECTIVE: To examine the association between regional hospital market concentration and hospital charges for hepatopancreaticobiliary surgical procedures. DESIGN, SETTING, AND PARTICIPANTS: This study included all patients undergoing hepatic or pancreatic resection in the Nationwide Inpatient Sample from January 1, 2003, through December 31, 2011. Hospital market concentration was assessed using a variable-radius Herfindahl-Hirschman Index (HHI) in the 2003, 2006, and 2009 Hospital Market Structure files. Data were analyzed from November 19, 2016, through March 2, 2017. INTERVENTIONS: Hepatic or pancreatic resection. MAIN OUTCOMES AND MEASURES: Multivariable mixed-effects log-linear models were constructed to determine the association between HHI and total costs and charges for hepatic or pancreatic resection. RESULTS: Weighted totals of 38 711 patients undergoing pancreatic resection (50.8% men and 49.2% women; median age, 65 years [interquartile range, 55-73 years]) and 52 284 patients undergoing hepatic resection (46.8% men and 53.2% women; median age, 59 years [interquartile range, 49-69 years]) were identified. Higher institutional volume was associated with lower cost of pancreatic resection (-5.4%; 95% CI, -10.0% to -0.5%; P = .03) and higher cost of hepatic resection (13.4%; 95% CI, 8.2% to 18.8%; P < .001). For pancreatic resections, costs were 5.5% higher (95% CI, 0.1% to 11.1%; P = .047) in unconcentrated hospital markets relative to moderately concentrated markets, although overall charges were 8.3% lower (95% CI, -14.0% to -2.3%; P = .008) in highly concentrated markets. For hepatic resections, hospitals in highly concentrated markets had 8.4% lower costs (95% CI, -13.0% to -3.6%; P = .001) compared with those in unconcentrated markets and charges that were 13.4% lower (95% CI, -19.3% to -7.1%; P < .001) compared with moderately concentrated markets and 10.5% lower (95% CI, -16.2% to -4.4%; P = .001) compared with unconcentrated markets. CONCLUSIONS AND RELEVANCE: Higher market concentration was associated with lower overall charges and lower costs of pancreatic and hepatic surgery. For complex, highly specialized procedures, hospital market consolidation may represent the best value proposition: better quality of care with lower costs.

Readmission after major surgery: effect of the postdischarge environment.

BACKGROUND: Although uncoordinated postdischarge care has been associated with poor clinical outcomes, the effect of discharge to a low healthcare resource area (LHRA) on readmission remains undetermined. We sought to assess how the quality of discharge area health resources impact readmission following major surgery. METHODS: This cross-sectional study was performed by linking Maryland state data for 2012-2015 to the Agency for Healthcare Research and Quality Area Health-Resource File. Patients undergoing one of 11 common surgical procedures were identified. Multivariable logistic regression was performed to assess the effect of discharge area health resource quality on readmission. RESULTS: A total of 76,747 patients were identified of which 9.4% were discharged to a high healthcare resource area (HHRA), whereas 81.9% of patients were discharged to an LHRA. Perioperative morbidity and length of stay were comparable between HHRA versus LHRA patients (both P > 0.05). Among all patients, 30-d and 90-d readmission was 6.5% and 12.4%, respectively. On multivariable analysis, discharge to LHRA was independently associated with a 19% (odds ratio = 1.19; 95% CI, 1.01-1.41; P = 0.043) and 18% (odds ratio = 1.18; 95% CI, 1.04-1.33; P = 0.010) greater odds of 30-d and 90-day readmission, respectively. CONCLUSIONS: Patients discharged to an area characterized by LHRA were more likely to be readmitted at 30 d and 90 d following index discharge.

Assessment of postdischarge complications after bariatric surgery: A National Surgical Quality Improvement Program analysis.

BACKGROUND: Little is reported about postdischarge complications after bariatric surgery. We sought to identify the rates of postdischarge complications, associated risk factors, and their influence on early hospital readmission. METHODS: Using the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) (2005-2013), we identified patients ≥18 years of age who underwent a bariatric operation with a primary diagnosis of morbid/severe obesity and a body mass index ≥35. The incidence of postdischarge complication was the primary outcome, and hospital readmission was the secondary outcome. The association between postdischarge complications and various patient factors was explored by the use of multivariable logistic regression. RESULTS: A total of 113,898 patients were identified with an overall postdischarge complication rate of 3.2% within 30 days of operation. The rates decreased from 2005 to 2006 (4.6%) to 2013 (3.0%) (P < .001). On average, postdischarge complications occurred 10 days postoperatively, with wound infection (49.4%), reoperation (30.7%), urinary tract infection (16.9%), shock/sepsis (12.4%), and organ space surgical-site infection (11.0%) being the most common. Patients undergoing open gastric bypass had the greatest postdischarge complication rate of 8.5%. Of those patients experiencing postdischarge complications, 51.6% were readmitted. The overall readmission rate was 4.9%. The factors associated most strongly with increased odds of postdischarge complications were body mass index ≥ 50, use of steroids, procedure type, predischarge complication, prolonged duration of stay, and prolonged operative time. CONCLUSION: Postdischarge complications after bariatric surgery represent a substantial source of patient morbidity and hospital readmissions. The majority of postdischarge complications are infection-related, including surgical-site infections and catheter-associated urinary tract infections. Adopting and implementing standardized pre- and postoperative strategies to decrease perioperative infection may help to decrease the rate of postdischarge complications and associated readmissions and enhance overall quality of care.

Teaching billing and coding to medical students: a pilot study.

Complex billing practices cost the US healthcare system billions of dollars annually. Coding for outpatient office visits [known as Evaluation & Management (E&M) services] is commonly particularly fraught with errors. The best way to insure proper billing and coding by practicing physicians is to teach this as part of the medical school curriculum. Here, in a pilot study, we show that medical students can learn well the basic principles from lectures. This approach is easy to implement into a medical school curriculum.