Telemetry Overuse and the Effect of Educational and Electronic Health Record-Based Interventions on an Academic Internal Medicine Ward.

OBJECTIVES: Guidelines for appropriate use of telemetry recommend monitoring for specific patient populations; however, many hospitalized patients receive telemetry monitoring without an indication. Clinical data and outcomes associated with nonindicated monitoring are not well studied. The objectives of our study were to evaluate the impact of an education and an order entry intervention on telemetry overuse and to identify the diagnoses and telemetry-related outcomes of patients who receive telemetry monitoring without guidelines indication. METHODS: A retrospective cohort study of hospitalized patients on internal medicine (IM) wards between 2015 and 2018 examining the effects of educational and order entry interventions at an academic urban medical center. A baseline cohort examining telemetry use was established. This was followed by the delivery of IM resident educational sessions regarding telemetry guidelines. In a subsequent intervention, the telemetry order entry system was modified with a constraint to require American Heart Association guidelines justification. RESULTS: Across all of the cohorts, 51% (n = 141) of patients lacked a guidelines-specified indication. These patients had variable diagnoses. The educational intervention alone did not result in significant differences in telemetry use by IM residents. The order entry intervention resulted in a significant increase in the proportion of guidelines-indicated patients and a decrease in nonindicated patients on telemetry. No safety events were noted in any group. CONCLUSIONS: A telemetry order entry system modification implemented following an educational intervention is more likely to reduce telemetry use than an educational intervention alone in IM resident practice. A variety of patients are monitored without evidence of need; therefore, the clinical impact of telemetry reduction is unlikely to be harmful.

Mycobacterium bovis Infection in African Wild Dogs, Kruger National Park, South Africa.

We screened African wild dogs (Lycaon pictus) in Kruger National Park, South Africa, for Mycobacterium bovis infection using an interferon-gamma release assay. We detected M. bovis sensitization in 20 of 21 packs; overall apparent infection prevalence was 83%. These animals experience high infection pressure, which may affect long-term survival and conservation strategies.

Declining water yield from forested mountain watersheds in response to climate change and forest mesophication.

Climate change and forest disturbances are threatening the ability of forested mountain watersheds to provide the clean, reliable, and abundant fresh water necessary to support aquatic ecosystems and a growing human population. Here, we used 76 years of water yield, climate, and field plot vegetation measurements in six unmanaged, reference watersheds in the southern Appalachian Mountains of North Carolina, USA to determine whether water yield has changed over time, and to examine and attribute the causal mechanisms of change. We found that annual water yield increased in some watersheds from 1938 to the mid-1970s by as much as 55%, but this was followed by decreases up to 22% by 2013. Changes in forest evapotranspiration were consistent with, but opposite in direction to the changes in water yield, with decreases in evapotranspiration up to 31% by the mid-1970s followed by increases up to 29% until 2013. Vegetation survey data showed commensurate reductions in forest basal area until the mid-1970s and increases since that time accompanied by a shift in dominance from xerophytic oak and hickory species to several mesophytic species (i.e., mesophication) that use relatively more water. These changes in forest structure and species composition may have decreased water yield by as much as 18% in a given year since the mid-1970s after accounting for climate. Our results suggest that changes in climate and forest structure and species composition in unmanaged forests brought about by disturbance and natural community dynamics over time can result in large changes in water supply.

Identifying human influences on atmospheric temperature.

We perform a multimodel detection and attribution study with climate model simulation output and satellite-based measurements of tropospheric and stratospheric temperature change. We use simulation output from 20 climate models participating in phase 5 of the Coupled Model Intercomparison Project. This multimodel archive provides estimates of the signal pattern in response to combined anthropogenic and natural external forcing (the fingerprint) and the noise of internally generated variability. Using these estimates, we calculate signal-to-noise (S/N) ratios to quantify the strength of the fingerprint in the observations relative to fingerprint strength in natural climate noise. For changes in lower stratospheric temperature between 1979 and 2011, S/N ratios vary from 26 to 36, depending on the choice of observational dataset. In the lower troposphere, the fingerprint strength in observations is smaller, but S/N ratios are still significant at the 1% level or better, and range from three to eight. We find no evidence that these ratios are spuriously inflated by model variability errors. After removing all global mean signals, model fingerprints remain identifiable in 70% of the tests involving tropospheric temperature changes. Despite such agreement in the large-scale features of model and observed geographical patterns of atmospheric temperature change, most models do not replicate the size of the observed changes. On average, the models analyzed underestimate the observed cooling of the lower stratosphere and overestimate the warming of the troposphere. Although the precise causes of such differences are unclear, model biases in lower stratospheric temperature trends are likely to be reduced by more realistic treatment of stratospheric ozone depletion and volcanic aerosol forcing.

Contemporary Management and Outcomes of Veterans Hospitalized With Alcohol Withdrawal: A Multicenter Retrospective Cohort Study.

OBJECTIVES: Few studies describe contemporary alcohol withdrawal management in hospitalized settings or review current practices considering the guidelines by the American Society of Addiction Medicine (ASAM). METHODS: We conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical or surgical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Demographic and comorbidity data were obtained from the Veteran Health Administration Corporate Data Warehouse. Inpatient management and hospital outcomes were obtained by chart review. Factors associated with treatment duration and complicated withdrawal were examined. RESULTS: Of the 594 patients included in this study, 51% were managed with symptom-triggered therapy alone, 26% with fixed dose plus symptom-triggered therapy, 10% with front loading regimens plus symptom-triggered therapy, and 3% with fixed dose alone. The most common medication given was lorazepam (87%) followed by chlordiazepoxide (33%), diazepam (14%), and phenobarbital (6%). Symptom-triggered therapy alone (relative risk [RR], 0.68; 95% confidence interval [CI], 0.57-0.80) and front loading with symptom-triggered therapy (RR, 0.75; 95% CI, 0.62-0.92) were associated with reduced treatment duration. Lorazepam (RR, 1.20; 95% CI, 1.02-1.41) and phenobarbital (RR, 1.28; 95% CI, 1.06-1.54) were associated with increased treatment duration. Lorazepam (adjusted odds ratio, 4.30; 95% CI, 1.05-17.63) and phenobarbital (adjusted odds ratio, 6.51; 95% CI, 2.08-20.40) were also associated with complicated withdrawal. CONCLUSIONS: Overall, our results support guidelines by the ASAM to manage patients with long-acting benzodiazepines using symptom-triggered therapy. Health care systems that are using shorter acting benzodiazepines and fixed-dose regimens should consider updating alcohol withdrawal management pathways to follow ASAM recommendations.

An evaluation of radiation therapy patient body mass index trends and potential impact on departmental resource planning.

INTRODUCTION: Radiation therapy (RT) offers a less invasive management option for bariatric cancer patients. As the proportion of Australians categorised overweight or obese approaches 70%, it is not well understood how this growth will impact RT departments. The aim of this study was to evaluate the current and potential future body mass index (BMI) of RT patients at one centre, with the purpose of identifying variables that may impact resource planning decisions. METHODS: De-identified demographic data including gender, age, diagnosis code, activity code and BMI were obtained from MOSAIQ® oncology information system for 5548 courses of RT commenced between 2017 and 2020, and retrospectively analysed. Descriptive statistics were used to summarise the data. Simple and multiple linear regression was used to analyse for statistically significant relationships between variables. RESULTS: Of all patient courses, 64% were overweight or obese. Average BMI increased over time by 0.3 kg/m2 per year. Courses related to the young and elderly had a lower average BMI. Breast, brain/skull, and pelvis/prostate treatment sites had a significant association with a higher average BMI. Thorax treatment sites had a lower average BMI, but this average is increasing at the fastest rate of all treatment sites. Prone breast courses had an average BMI 5.58 kg/m2 higher than IMRT/VMAT courses. CONCLUSION: Results demonstrate that patient BMI is increasing. Resources related to breast courses (breast board, prone board) and thorax courses (lung board) may experience increased strain in the future. Modifications to department workflow and scheduling are likely required. Further research into staffing implications is recommended.

Projection of Sediment Loading from Pearl River Basin, Mississippi into Gulf of Mexico under a Future Climate with Afforestation.

Sediment load in rivers is recognized as both a carrier and a potential source of contaminants. Sediment deposition significantly changes river flow and morphology, thereby affecting stream hydrology and aquatic life. We projected sediment load from the Pearl River basin (PRB), Mississippi into the northern Gulf of Mexico under a future climate with afforestation using the SWAT (Soil and Water Assessment Tool)-based HAWQS (Hydrologic and Water Quality System) model. Three simulation scenarios were developed in this study: (1) the past scenario for estimating the 40-year sediment load from 1981 to 2020; (2) the future scenario for projecting the 40-year sediment load from 2025 to 2064, and (3) the future afforestation scenario that was the same as the future scenario, except for converting the rangeland located in the middle section of the Pearl River watershed of the PRB into the mixed forest land cover. Simulations showed a 16% decrease in sediment load for the future scenario in comparison to the past scenario due to the decrease in future surface runoff. Over both the past and future 40 years, the monthly maximum and minimum sediment loads occurred, respectively, in April and August; whereas the seasonal sediment load followed the order: spring > winter > summer > fall. Among the four seasons, winter and spring accounted for about 86% of sediment load for both scenarios. Under the future 40-year climate conditions, a 10% reduction in annual average sediment load with afforestation was observed in comparison to without afforestation. This study provides new insights into how a future climate with afforestation would affect sediment load into the northern Gulf of Mexico.

Riparian buffers increase future baseflow and reduce peakflows in a developing watershed.

Land conversion and climate change are stressing freshwater resources. Riparian areas, streamside vegetation/forest land, are critical for regulating hydrologic processes and riparian buffers are used as adaptive management strategies for mitigating land conversion effects. However, our ability to anticipate the efficacy of current and alternative riparian buffers under changing conditions remains limited. To address this information gap, we simulated hydrologic responses for different levels of buffer protection under a future scenario of land/climate change through the year 2060. We used the Soil and Water Assessment Tool (SWAT) to project future streamflow in the Upper Neuse River watershed in North Carolina, USA. We tested the capacity of riparian buffers to mitigate the effects of future land use and climate change on daily mean streamflow under three buffer treatments: present buffer widths and fully forested 15 m and 30 m buffers throughout the basin. The treatments were tested using a combination of a future climate change scenario and landcover projections that indicated a doubling of low-intensity development between 2017 and 2060. In areas with >50 % development, the 30 m buffers were particularly effective at increasing average daily streamflow during the lowest flow events by 4 % and decreasing flow during highest flow events by 3 % compared to no buffer protection. In areas between 20 and 50 % development, both 15 m and 30 m buffers reduced low flow by 8 % with minimal effects on high flow. Results indicate that standardized buffers might be more effective at a local scale with further research needing to focus on strategic buffer placement at the watershed scale. These findings highlight a novel approach for integrating buffers into hydrologic modeling and potential for improved methodology. Understanding the effects of riparian buffers on streamflow is crucial given the pressing need to develop innovative strategies that promote the conservation of invaluable ecosystem services.

Inter-basin surface water transfers database for public water supplies in conterminous United States, 1986-2015.

The manipulation of water resources is a common human solution to water-related problems. Of particular interest because of impacts on both source and destination is the anthropogenic movement of water from one basin to another, or inter-basin transfers (IBTs). In the United States, IBTs occur widely in both wet and dry regions, but IBT data are not collated and served in a coordinated way. Thus researchers wishing to account for transfers between basins have faced difficulty in doing so. Here we present the outcome of a systematic investigation into inter-basin surface water transfers connected with public water supplies in the conterminous United States (CONUS), 1986 to 2015. The present open-access geodatabase includes transfer volumes collected, evaluated, and compiled from disparate sources. We provide an updated snapshot of CONUS IBTs at a higher spatial resolution of points of withdrawal and delivery than previous datasets. This paper puts the national inter-basin transfer data in context, and shows how we acquired, structured, and validated the locations and volumes of surface water transfers in public water systems.

Forested watersheds provide the highest water quality among all land cover types, but the benefit of this ecosystem service depends on landscape context.

Conversion of natural land cover can degrade water quality in water supply watersheds and increase treatment costs for Public Water Systems (PWSs), but there are few studies that have fully evaluated land cover and water quality relationships in mixed use watersheds across broad hydroclimatic settings. We related upstream land cover (forest, other natural land covers, development, and agriculture) to observed and modeled water quality across the southeastern US and specifically at 1746 PWS drinking water intake facilities. While there was considerable complexity and variability in the relationship between land cover and water quality, results suggest that Total Nitrogen (TN), Total Phosphorus (TP) and Suspended Sediment (SS) concentrations decrease significantly with increasing forest cover, and increase with increasing developed or agricultural cover. Catchments with dominant (>90 %) agricultural land cover had the greatest export rates for TN, TP, and SS based on SPARROW model estimates, followed by developed-dominant, then forest- and other-natural-dominant catchments. Variability in modeled TN, TP, and SS export rates by land cover type was driven by variability in natural background sources and catchment characteristics that affected water quality even in forest-dominated catchments. Both intake setting (i.e., run-of-river or reservoir) and upstream land cover were important determinants of water quality at PWS intakes. Of all PWS intakes, 15 % had high raw water quality, and 85 % of those were on reservoirs. Of the run-of-river intakes with high raw water quality, 75 % had at least 50 % forest land cover upstream. In addition, PWS intakes obtaining surface water supply from smaller upstream catchments may experience the largest losses of natural land cover based on projections of land cover in 2070. These results illustrate the complexity and variability in the relationship between land cover and water quality at broad scales, but also suggest that forest conservation can enhance the resilience of drinking water supplies.

Cutaneous apocrine gland neoplasia in 16 captive African wild dogs (Lycaon pictus).

This retrospective study documents the occurrence of single and multiple cutaneous apocrine gland tumours (CATs) on the dorsal midline of 16 captive African wild dogs (AWDs, Lycaon pictus) derived from 161 submissions to diagnostic laboratories in South Africa, France and Germany between 1997 and 2022. Animals included in the study came from zoological institutions in South Africa (n = 2), France (n = 5) and Germany (n = 1) and ranged from 5 to 14 years of age. Fifteen affected animals were female (94%) and one was male. CATs presented as raised, hairless, multilobular, grey firm masses, consistently located along the dorsal midline. Apart from a single cutaneous apocrine adenoma and a cystadenoma occurring concurrently with two non-cystic adenocarcinomas, neoplasms were consistent with malignant cutaneous apocrine adenocarcinomas with lymphatic spread and visceral metastases. Advanced age and female sex were identified as risk factors. A genetic component or association with the increasing use of GnRH agonist contraceptives was suspected but could not be established. This study highlights the need for close clinical monitoring of AWDs over the age of 5 years for the development of CATs along the dorsal midline and supports early surgical intervention. More research is needed to determine the role of inbreeding, endocrine changes and husbandry factors that may play a role in the development of CATs on the dorsal midline of AWDs.

Sinonasal Meningioma in a Siberian Tiger (Panthera tigris altaica).

Meningiomas are the most common primary brain tumour in dogs and cats. However, whilst there are numerous reports of extracranial (spinal, orbital and sinonasal) meningiomas in the dog, there have only been a few case reports of spinal meningiomas, and no post-mortem confirmed orbital or sinonasal meningiomas in cats. In this report, a 20-year-old captive tiger (Panthera tigris altaica) with a history of chronic ocular inflammation resulting in enucleation, spontaneously developed tetanic convulsions (epileptic seizures) that over a 2-year period resulted in a gradually worsening condition and the animal was eventually euthanized. At autopsy, a focal, expansile, neoplastic mass was found in the caudal nasal cavity midline, abutting the cribriform plate and slightly compressing the calvarium. Histological analysis revealed nasal turbinates attached to a well-circumscribed expansile multi-lobular mass consisting of interlacing whorls and streams of neoplastic cells supported by a variably fibrous to microcystic collagenous matrix displaying rare psammoma bodies. The diagnosis was sinonasal transitional meningioma. This is the first report of a captive wild felid with an extracranial meningioma, specifically a tiger with a sinonasal transitional meningioma.

Effects of Rhododendron removal and prescribed fire on bees and plants in the southern Appalachians.

Rhododendron maximum is an evergreen shrub native to the Appalachian Mountains of North America that has expanded in recent decades due to past disturbances and land management. The purpose of this study was to explore how bees and plants were affected by the experimental removal of R. maximum followed by a prescribed fire in one watershed compared to a neighboring reference watershed. Bees and plants were sampled for three years in both watersheds. Comparisons were based on the rarefaction and extrapolation sampling curves of Hill numbers as well as multivariate methods to assess effects on community composition. Bee richness, Shannon's diversity, and Simpson's diversity did not differ between watersheds in the year after removal but were all significantly higher in the removal watershed in year two, following the prescribed fire. Bee Shannon's diversity and Simpson's diversity, but not richness, remained significantly higher in the removal watershed in the third year. Similar but weaker patterns were observed for plants. Comparisons of community composition found significant differences for bees in the second and third year and significant differences for plants in all three years. For both groups, significant indicator taxa were mostly associated with the removal watershed. Because bees appeared to respond more strongly to the prescribed fire than to the removal of R. maximum and these benefits weakened considerably one year after the fire, clearing R. maximum does not appear to dramatically improve pollinator habitat in the southern Appalachians. This conclusion is underscored by the fact that about one quarter of the bee species in our study area were observed visiting R. maximum flowers. The creation of open areas with wildflowers may be a better way to benefit bees in this region judging from the high diversity of bees captured in the small roadside clearings in this study.

The implementation of MOSAIQ-based image-guided radiation therapy image matching within radiation therapy education.

Image-guided radiation therapy (IGRT) technologies are routinely used by radiation therapists (RTs) in clinical departments. However, there is limited literature on the acquisition and assessment of IGRT image-matching competencies in undergraduate educational environments. This commentary paper aims to share the authors' experiences in the development of teaching IGRT and image-matching concepts in an undergraduate radiation therapy programme. It outlines how MOSAIQ oncology information systems (OIS) have enabled the university to embed hands-on IGRT image matching on a range of clinical cases. The hands-on exposure to case-based planar and volumetric kilovoltage (kV) image matching has resulted in improved teaching and better preparation of students for clinical IGRT encounters. Students are likely to benefit from critical image assessment and decision-making as well as the improved engagement in teaching and learning.

Radiographic analysis of the thickness of the cranial bones in captive compared to wild-living cheetahs and in cheetahs with hypovitaminosis A.

Captive cheetahs often demonstrate a high incidence of diseases in which vitamin A imbalances are implicated. These can occur even under controlled and optimised feeding regimens, which is why surveillance of vitamin A status is mandatory in the successful health management of cheetahs. Serum levels of the vitamin do not reflect the true vitamin A status and liver tissue analysis is rather impractical for routine application in large felids. A biomarker for evaluating overt and subclinical vitamin A deficiency in cheetahs is needed. This study evaluates whether increased calvarial bone thickness can be detected on routine skull radiographs of vitamin A deficient cheetahs compared to unaffected animals, and secondly, evaluates whether there is increased bone thickness in clinically sound captive cheetahs in general compared to wild-living controls. Bone thickness in the neuro- and splanchnocranium was measured in 138 skull radiographs. Significant thickening of the parietal bones was found in latero-lateral radiographs of immature cheetahs (< 12 months) with vitamin A deficiency. This finding may allow a presumptive diagnosis of hypovitaminosis A in immature cheetahs. A general difference in skull thickness between free-living and captive cheetahs was not found.

Metastatic Cutaneous Melanoma in a White African Lioness (Panthera leo).

Malignant melanomas tend to be locally destructive, aggressive tumours commonly associated with recurrence and/or metastasis. In this report, a 13-year-old captive white African lioness (Panthera leo), with a recent history of intermittent bouts of lethargy and inappetence, presented with a distended abdomen (due to ascites) and a small, round crusty lesion on the ear. An abdominal ultrasound showed the presence of masses on the liver and an exploratory laparotomy revealed multiple pale lesions on the liver and omentum. Histopathology revealed sheets of pleomorphic neoplastic cells compressing the non-neoplastic liver tissue. Similar neoplastic cells had multifocally expanded and effaced omentum adipose tissue, as well as formed a well-circumscribed mass in the ear sample, extending from close to the epidermis to the lateral and deep margins of the section. All three tissue samples had a high mitotic index (15 per 10 HPF), and critically, in the ear sample, there were rafts of neoplastic cells in the lymphatics, indicating lymphovascular invasion. Immunohistochemistry for the melanoma marker, PNL-2, showed strong positivity in all three tissue samples. Thus, the diagnosis was of malignant melanoma with metastasis to the liver and omentum. This is the first report of metastatic cutaneous melanoma in a lion.

The Impact of Artificial Intelligence and Machine Learning in Radiation Therapy: Considerations for Future Curriculum Enhancement.

Artificial intelligence (AI) and machine learning (ML) approaches have caught the attention of many in health care. Current literature suggests there are many potential benefits that could transform future clinical workflows and decision making. Embedding AI and ML concepts in radiation therapy education could be a fundamental step in equipping radiation therapists (RTs) to engage in competent and safe practice as they utilise clinical technologies. In this discussion paper, the authors provide a brief review of some applications of AI and ML in radiation therapy and discuss pertinent considerations for radiation therapy curriculum enhancement. As the current literature suggests, AI and ML approaches will impose changes to routine clinical radiation therapy tasks. The emphasis in RT education could be on critical evaluation of AI and ML application in routine clinical workflows and gaining an understanding of the impact on quality assurance, provision of quality of care and safety in radiation therapy as well as research. It is also imperative RTs have a broader understanding of AI/ML impact on health care, including ethical and legal considerations. The paper concludes with recommendations and suggestions to deliberately embed AI and ML aspects in RT education to empower future RT practitioners.

Leadership in the radiation therapy profession: The importance of understanding the potential benefits and theoretical perspectives.

The incorporation of leadership concepts is at the forefront of agendas to advance the quality of patient care and innovation in many healthcare professions. In this Commentary, the authors draw upon evidence from the literature to discuss the theoretical perspectives of leadership and potential value in radiation therapy practice. For the patients to be provided with safe and high-quality treatment, continuous change and improvement are necessary. Leadership has the potential to influence behaviour change for practitioners and core organisational culture. Several leadership styles such as the transformational leadership can be applied to achieve a higher level of patient care and improve the likelihood of enhancing quality and efficiency in healthcare. These are also paramount to the success of radiation therapy practice. Hence, a higher priority should be placed on developing leadership in the Radiation Therapist (RT) workforce and educating new graduates of the potential benefits.

The Application of the Virtual Environment for Radiotherapy Training to Strengthen IGRT Education.

The use of simulation to enhance the quality of preclinical teaching and learning in radiation therapy is increasing. This article discusses the use of the Virtual Environment for Radiotherapy Training (VERT) in supporting teaching on image-guided radiation therapy (IGRT) and image matching concepts. The authors review the capabilities of VERT and discuss how it is currently applied in undergraduate radiation therapy teaching. The integration of IGRT theory with hands-on image matching practice using VERT simulation in educational environments has many potential benefits. These include the potential to strengthen the students' knowledge and skills in online-image acquisition and review of planar two-dimensional images and cone beam computed tomography images. It is anticipated that learner engagement will improve as well as refine analytical skills and confident practice in critical assessment of IGRT images. The authors encourage the utilization of technology that provides students with hands-on skills so they are better prepared for clinical environments.

A contribution to age determination of cheetahs (Acinonyx jubatus) based on radiographic analysis of the skull and postcranial morphology.

The aim of this retrospective cross-sectional study was to present comprehensive information about the age-dependent change of skeletal characteristics in captive cheetahs with known age and to assess the benefit of these variables for age estimation in this species. Radiographs of 162 known-age captive and semi-captive cheetahs were retrospectively examined and age-related changes of skull, axial and appendicular skeletal systems were documented. Metric and non-metric variables were used. These parameters were checked for the best correlation with age using a multiple stepwise regression analysis. An overview about the time frames, in which ossification centers appeared and physeal closure occurred is presented. Multiple stepwise regression analysis revealed the status of closure of the coronal suture, the maximum length of the frontal sinus, the condylobasal-, hard palate, and facial length are most significantly correlated with age. Together with the pulp size of the upper canine, these values can be used for an age approximation in cheetahs.