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BACKGROUND: Management of geriatric trauma patients requires balancing chronic comorbidities with acute injuries. We developed a care model in which patients are managed by hospitalists with trauma-centered education and hypothesized that clinical outcomes would be similar to outcomes in patients primarily managed by trauma surgeons. METHODS: This was a retrospective study of trauma patients aged ≥65 from January 2020 to December 2021. Groups were defined by admitting service: trauma surgery service (TSS) or geriatric trauma hospitalist service (GTHS). The primary outcome was in-hospital mortality. Regression analyses and inverse probability treatment weighted (IPTW) propensity score (PS) analyses were performed to determine the association between admitting service and outcomes. RESULTS: A total of 1004 patients were eligible for inclusion-580 GTHS and 424 TSS admissions. GTHS patients were older (82 vs. 74, p < 0.001), more likely to have suffered blunt trauma (99.5% vs. 95%, p < 0.001), more likely to have comorbidities (91.2% vs. 87%, p < 0.001), had higher Charlson Comorbidity Indexes (CCIs), and had lower median injury severity scores (9 vs. 13, p < 0.001). Rates of mortality, delirium, 30-day readmission, and overall complications were low and similar between groups. While TSS patients were likely to be discharged home, GTHS had more discharges to skilled nursing facilities and longer length of stay (LOS). On multivariable analysis adjusted for age, ISS, CCI, and sex, patients admitted to GTHS had lower odds of death with an odds ratio of 0.15 (95% confidence interval [CI] 0.02-0.75, p = 0.03) when compared to TSS. On IPTW PS analysis, patients admitted to GTHS had similar odds of death with an odds ratio of 0.3 (95% CI 0.06-1.6, p = 0.16). CONCLUSIONS: Protocolized admission criteria to a GTHS resulted in similar low mortality rates but longer LOS when compared to patients admitted to a TSS. This care model may inform other trauma centers in developing their strategies for managing the increasing volume of vulnerable injured older adults.
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BACKGROUND: Despite documented associations between social determinants of health and outcomes post-congenital heart surgery, clinical risk models typically exclude these factors. OBJECTIVES: The study sought to characterize associations between social determinants and operative and longitudinal mortality as well as assess impacts on risk model performance. METHODS: Demographic and clinical data were obtained for all congenital heart surgeries (2006-2021) from locally held Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources Society of Thoracic Surgeons Congenital Heart Surgery Database data. Neighborhood-level American Community Survey and composite sociodemographic measures were linked by zip code. Model prediction, discrimination, and impact on quality assessment were assessed before and after inclusion of social determinants in models based on the 2020 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model. RESULTS: Of 14,173 total index operations across New York State, 12,321 cases, representing 10,271 patients at 8 centers, had zip codes for linkage. A total of 327 (2.7%) patients died in the hospital or before 30 days, and 314 children died by December 31, 2021 (total n = 641; 6.2%). Multiple measures of social determinants of health explained as much or more variability in operative and longitudinal mortality than clinical comorbidities or prior cardiac surgery. Inclusion of social determinants minimally improved models' predictive performance (operative: 0.834-0.844; longitudinal 0.808-0.811), but significantly improved model discrimination; 10.0% more survivors and 4.8% more mortalities were appropriately risk classified with inclusion. Wide variation in reclassification was observed by site, resulting in changes in the center performance classification category for 2 of 8 centers. CONCLUSIONS: Although indiscriminate inclusion of social determinants in clinical risk modeling can conceal inequities, thoughtful consideration can help centers understand their performance across populations and guide efforts to improve health equity.
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Procedimientos Quirúrgicos Cardíacos , Cardiopatías Congénitas , Determinantes Sociales de la Salud , Humanos , Cardiopatías Congénitas/cirugía , Cardiopatías Congénitas/mortalidad , Masculino , Femenino , Procedimientos Quirúrgicos Cardíacos/mortalidad , Lactante , Preescolar , Medición de Riesgo/métodos , Niño , Recién Nacido , New York/epidemiologíaRESUMEN
Heat pumps (HPs) have emerged as a key technology for reducing energy use and greenhouse gas emissions. This study evaluates the potential switch to air-to-air HPs (AAHPs) in Toulouse, France, where conventional space heating is split between electric and gas sources. In this context, we find that AAHPs reduce heating energy consumption by 57% to 76%, with electric heating energy consumption decreasing by 6% to 47%, resulting in virtually no local heating-related CO2 emissions. We observe a slight reduction in near-surface air temperature of up to 0.5 °C during cold spells, attributable to a reduction in sensible heat flux, which is unlikely to compromise AAHPs operational efficiency. While Toulouse's heating energy mix facilitates large energy savings, electric energy consumption may increase in cities where gas or other fossil fuel sources prevail. Furthermore, as AAHPs efficiency varies with internal and external conditions, their impact on the electrical grid is more complex than conventional heating systems. The results underscore the importance of matching heating system transitions with sustainable electricity generation to maximize environmental benefits. The study highlights the intricate balance between technological advancements in heating and their broader environmental and policy implications, offering key insights for urban energy policy and sustainability efforts.
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Little is known about the possibility of reversing age-related biological changes when they have already occurred. To explore this, we have characterized the effects of reducing insulin/IGF-1 signaling (IIS) during old age. Reduction of IIS throughout life slows age-related decline in diverse species, most strikingly in the nematode Caenorhabditis elegans. Here we show that even at advanced ages, auxin-induced degradation of DAF-2 in single tissues, including neurons and the intestine, is still able to markedly increase C. elegans lifespan. We describe how reversibility varies among senescent changes. While senescent pathologies that develop in mid-life were not reversed, there was a rejuvenation of the proteostasis network, manifesting as a restoration of the capacity to eliminate otherwise intractable protein aggregates that accumulate with age. Moreover, resistance to several stressors was restored. These results support several new conclusions. (1) Loss of resilience is not solely a consequence of pathologies that develop in earlier life. (2) Restoration of proteostasis and resilience by inhibiting IIS is a plausible cause of the increase in lifespan. And (3), most interestingly, some aspects of the age-related transition from resilience to frailty can be reversed to a certain extent. This raises the possibility that the effect of IIS and related pathways on resilience and frailty during aging in higher animals might possess some degree of reversibility.
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Additive manufacturing (AM) offers a variety of material manufacturing techniques for a wide range of applications across many industries. Most efforts at process optimization and exposure assessment for AM are centered around the manufacturing process. However, identifying the material allocation and potentially harmful exposures in end-of-life (EoL) management is equally crucial to mitigating environmental releases and occupational health impacts within the AM supply chain. This research tracks the allocation and potential releases of AM EoL materials within the US through a material flow analysis. Of the generated AM EoL materials, 58% are incinerated, 33% are landfilled, and 9% are recycled by weight. The generated data set was then used to examine the theoretical occupational hazards during AM EoL material management practices through generic exposure scenario assessment, highlighting the importance of ventilation and personal protective equipment at all stages of AM material management. This research identifies pollution sources, offering policymakers and stakeholders insights to shape pollution prevention and worker safety strategies within the US AM EoL management pathways.
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Exposición Profesional , Humanos , ReciclajeRESUMEN
Aging clocks have provided one of the most important recent breakthroughs in the biology of aging, and may provide indicators for the effectiveness of interventions in the aging process and preventive treatments for age-related diseases. The reproducibility of accurate aging clocks has reinvigorated the debate on whether a programmed process underlies aging. Here we show that accumulating stochastic variation in purely simulated data is sufficient to build aging clocks, and that first-generation and second-generation aging clocks are compatible with the accumulation of stochastic variation in DNA methylation or transcriptomic data. We find that accumulating stochastic variation is sufficient to predict chronological and biological age, indicated by significant prediction differences in smoking, calorie restriction, heterochronic parabiosis and partial reprogramming. Although our simulations may not explicitly rule out a programmed aging process, our results suggest that stochastically accumulating changes in any set of data that have a ground state at age zero are sufficient for generating aging clocks.
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Envejecimiento , Metilación de ADN , Procesos Estocásticos , Envejecimiento/fisiología , Envejecimiento/genética , Humanos , Relojes Biológicos/fisiología , Relojes Biológicos/genética , Restricción Calórica , Animales , Parabiosis , Fumar , Simulación por Computador , Modelos Biológicos , Transcriptoma , MasculinoRESUMEN
Purpose: Emerging data suggest that acetaminophen lowers intraocular pressure (IOP) and has the potential to be repurposed as pharmacotherapy to treat open-angle glaucoma. However, pharmacokinetic data are lacking. This study aims to describe the pharmacokinetics of topical acetaminophen and its metabolite [N-arachidonoylaminophenol (AM404)] when administered individually and in combination, and to determine its effect on IOP in the ocular normotensive adult New Zealand White Rabbit (NZWR). Methods: A randomized control trial was conducted using topical 1% acetaminophen and 1% AM404. The study was divided into two sub-studies using both paired-eye and two-eye designs. Results: The mean [95% confidence interval of the mean (95% CI)] concentration of acetaminophen detected in the aqueous humor (AH) was 4.09 ppm (3.18-5.00) at 2 h and 0.92 ppm (0.60-1.24) at 4 h after an immediate dose of topical acetaminophen. The integral IOP, defined as the integral of IOP change from baseline over time, was -5.1 mmHgâ h (95% CI: -10 to 0.41) for control,-7.5 mmHgâ h (95% CI: -14 to -1.1) for half-hourly acetaminophen, and -4.4 mmHgâ h (95% CI: -14 to 5.5) for hourly acetaminophen over a 4-h period. When comparing topical acetaminophen with AM404 dosed half-hourly over a 4-h period, the integral IOP was -2.3 mmHgâ h (95% CI: -5.9 to 1.3) for control,-2.0 mmHgâ h (95% CI: -5.6 to 1.7) for AM404, -1.7 mmHgâ h (95% CI: -4.5 to 1.2) for acetaminophen, and -3.2 mmHgâ h (95% CI: -5.4 to -0.96) for acetaminophen/AM404 combined. Conclusions: Acetaminophen, but not its metabolite AM404, penetrated the multilayered cornea via passive diffusion in a dose-dependent fashion. There was a nonsignificant tendency to cause a lowering of IOP over the 4-h dosing period with higher AH concentrations of acetaminophen. Topical AM404 did not show a significant IOP-lowering effect.
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Circumflex aortic arch with coarctation and anomalous origin of the left pulmonary artery from the aorta are rare cardiovascular anomalies. These conditions can lead to early pulmonary hypertension and challenging management. Early diagnosis and surgical intervention are beneficial for optimal outcome. We present a case where both anomalies coexisted and were repaired with aortic uncrossing, arch augmentation, and reimplantation of the left pulmonary artery. To our knowledge, this is the first documented instance of these anomalies coexisting and being repaired in the neonatal period.
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Aorta Torácica , Arteria Pulmonar , Humanos , Arteria Pulmonar/anomalías , Arteria Pulmonar/cirugía , Arteria Pulmonar/diagnóstico por imagen , Recién Nacido , Aorta Torácica/anomalías , Aorta Torácica/cirugía , Aorta Torácica/diagnóstico por imagen , Coartación Aórtica/cirugía , Anomalías Múltiples/cirugía , Masculino , Procedimientos Quirúrgicos Vasculares/métodos , FemeninoRESUMEN
The brain's remarkable properties arise from the collective activity of millions of neurons. Widespread application of dimensionality reduction to multi-neuron recordings implies that neural dynamics can be approximated by low-dimensional "latent" signals reflecting neural computations. However, can such low-dimensional representations truly explain the vast range of brain activity, and if not, what is the appropriate resolution and scale of recording to capture them? Imaging neural activity at cellular resolution and near-simultaneously across the mouse cortex, we demonstrate an unbounded scaling of dimensionality with neuron number in populations up to 1 million neurons. Although half of the neural variance is contained within sixteen dimensions correlated with behavior, our discovered scaling of dimensionality corresponds to an ever-increasing number of neuronal ensembles without immediate behavioral or sensory correlates. The activity patterns underlying these higher dimensions are fine grained and cortex wide, highlighting that large-scale, cellular-resolution recording is required to uncover the full substrates of neuronal computations.
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Neuronas , Animales , Neuronas/fisiología , Ratones , Recuento de Células , Modelos Neurológicos , Corteza Cerebral/citología , Corteza Cerebral/fisiología , Potenciales de Acción/fisiología , Masculino , Ratones Endogámicos C57BLRESUMEN
This work develops and evaluates a self-navigated variable density spiral (VDS)-based manifold regularization scheme to prospectively improve dynamic speech magnetic resonance imaging (MRI) at 3 T. Short readout duration spirals (1.3-ms long) were used to minimize sensitivity to off-resonance. A custom 16-channel speech coil was used for improved parallel imaging of vocal tract structures. The manifold model leveraged similarities between frames sharing similar vocal tract postures without explicit motion binning. The self-navigating capability of VDS was leveraged to learn the Laplacian structure of the manifold. Reconstruction was posed as a sensitivity-encoding-based nonlocal soft-weighted temporal regularization scheme. Our approach was compared with view-sharing, low-rank, temporal finite difference, extra dimension-based sparsity reconstruction constraints. Undersampling experiments were conducted on five volunteers performing repetitive and arbitrary speaking tasks at different speaking rates. Quantitative evaluation in terms of mean square error over moving edges was performed in a retrospective undersampling experiment on one volunteer. For prospective undersampling, blinded image quality evaluation in the categories of alias artifacts, spatial blurring, and temporal blurring was performed by three experts in voice research. Region of interest analysis at articulator boundaries was performed in both experiments to assess articulatory motion. Improved performance with manifold reconstruction constraints was observed over existing constraints. With prospective undersampling, a spatial resolution of 2.4 × 2.4 mm2/pixel and a temporal resolution of 17.4 ms/frame for single-slice imaging, and 52.2 ms/frame for concurrent three-slice imaging, were achieved. We demonstrated implicit motion binning by analyzing the mechanics of the Laplacian matrix. Manifold regularization demonstrated superior image quality scores in reducing spatial and temporal blurring compared with all other reconstruction constraints. While it exhibited faint (nonsignificant) alias artifacts that were similar to temporal finite difference, it provided statistically significant improvements compared with the other constraints. In conclusion, the self-navigated manifold regularized scheme enabled robust high spatiotemporal resolution dynamic speech MRI at 3 T.
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Imagen por Resonancia Magnética , Habla , Humanos , Habla/fisiología , Algoritmos , Masculino , Estudios Prospectivos , Adulto , FemeninoRESUMEN
INTRODUCTION: The Assessment of Blood Consumption (ABC) score is a previously validated scoring system designed to predict which severely injured trauma patients will require massive transfusion. When the ABC score is used in the prehospital setting to activate massive transfusion at the receiving hospital, a 23% decrease in mortality has been demonstrated. However, the ABC score was developed and validated using hospital data from the emergency department (ED). The sensitivity and specificity of the ABC score when calculated using data from the prehospital setting are unknown. We hypothesized that the sensitivity and specificity of the prehospital ABC score will be similar to the sensitivity and specificity of the ED ABC score. METHODS: A 5-year retrospective analysis (2015-2019) of highest-activation adult trauma patients arriving to a quaternary Level I trauma center by hospital-based helicopter air medical service (HEMS) was performed. Demographic, prehospital, ED triage, and blood product utilization data were collected. Prehospital ABC score was calculated using the highest heart rate, lowest systolic blood pressure, and focused assessment with sonography for trauma (FAST) exam results obtained prior to arrival at the trauma center. ED ABC score was calculated using ED triage vital signs and ED FAST results. Sensitivity, specificity, positive predictive value, negative predictive value, and the area under the receiver operating characteristics (AUROC) curve were calculated for each ABC score. RESULTS: 2,067 patients met inclusion criteria. Mean age 39 (±17) years, 76% male, 22% penetrating mechanism. Of these, 128 patients (6%) received massive transfusion using the definition from the original study. Prehospital ABC score at a cutoff of 2 was 51% sensitive and 85% specific for predicting massive transfusion, with 83% correctly classified and an AUROC = 0.73. ED ABC score at the same cutoff was 60% sensitive and 84% specific, with 83% correctly classified and an AUROC = 0.81. By logistic regression, the odds of massive transfusion increased by 2.76 for every 1-point increase in prehospital ABC score (95%CI 2.25-3.37, p < 0.001). CONCLUSIONS: The ABC score is a useful prehospital tool for identifying who will require massive transfusion. Future studies to evaluate the effect of the prehospital ABC score on clinical care and mortality are necessary.
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Servicios Médicos de Urgencia , Heridas y Lesiones , Adulto , Femenino , Humanos , Masculino , Transfusión Sanguínea , Puntaje de Gravedad del Traumatismo , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Sensibilidad y Especificidad , Heridas y Lesiones/diagnóstico , Persona de Mediana EdadRESUMEN
Surgical repair of right aortic arch and aberrant left subclavian artery has traditionally involved ligamentum division. Such patients can have stenosis at the origin of the aberrant subclavian artery either at the time of presentation or later. The more recently popularized repair involving resection of Kommerell diverticulum with transfer of the subclavian artery to the left carotid artery allows resection of the stenotic segment and serves as an effective treatment for subclavian stenosis as well. We present three cases of early repair of this arch anomaly with associated subclavian stenosis repaired successfully in that manner.
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Anomalías Cardiovasculares , Divertículo , Cardiopatías Congénitas , Humanos , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/cirugía , Arteria Subclavia/anomalías , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aorta Torácica/anomalías , Constricción Patológica , Divertículo/complicaciones , Divertículo/diagnóstico por imagen , Divertículo/cirugía , Anomalías Cardiovasculares/complicaciones , Anomalías Cardiovasculares/diagnóstico por imagen , Anomalías Cardiovasculares/cirugía , Cardiopatías Congénitas/complicacionesRESUMEN
INTRODUCTION: Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL). METHODS: The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference. RESULTS: Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 - 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 - 0.52) DEF versus 0.31 (IQR -0.03 - 0.43) DCL, and at six months 0.51 (IQR 0.30 - 0.74) DEF versus 0.50 (IQR 0.28 - 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively. CONCLUSIONS: Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.
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Traumatismos Abdominales , Laparotomía , Femenino , Humanos , Masculino , Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/cirugía , Cuidados Posteriores , Teorema de Bayes , Laparotomía/efectos adversos , Alta del Paciente , Calidad de Vida , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Neurodegenerative disorders, such as Alzheimer's disease (AD) or Huntington's disease (HD), are linked to protein aggregate neurotoxicity. According to the "cholinergic hypothesis," loss of acetylcholine (ACh) signaling contributes to the AD pathology, and therapeutic restoration of ACh signaling is a common treatment strategy. How disease causation and the effect of ACh are linked to protein aggregation and neurotoxicity remains incompletely understood, thus limiting the development of more effective therapies. Here, we show that BAZ-2, the Caenorhabditis elegans ortholog of human BAZ2B, limits ACh signaling. baz-2 mutations reverse aggregation and toxicity of amyloid-beta as well as polyglutamine peptides, thereby restoring health and lifespan in nematode models of AD and HD, respectively. The neuroprotective effect of Δbaz-2 is mediated by choline acetyltransferase, phenocopied by ACh-esterase depletion, and dependent on ACh receptors. baz-2 reduction or ectopic ACh treatment augments proteostasis via induction of the endoplasmic reticulum unfolded protein response and the ubiquitin proteasome system.
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Enfermedad de Alzheimer , Enfermedad de Huntington , Factores Generales de Transcripción , Animales , Humanos , Acetilcolina/metabolismo , Enfermedad de Alzheimer/metabolismo , Péptidos beta-Amiloides/metabolismo , Proteínas que Contienen Bromodominio , Caenorhabditis elegans/metabolismo , Proteostasis , Factores Generales de Transcripción/metabolismoRESUMEN
Objectives: Recent studies evaluating fibrinogen replacement in trauma, along with newly available fibrinogen-based products, has led to an increase in debate on where products such as cryoprecipitate belong in our resuscitation strategies. We set out to define the phenotype and outcomes of those with hypofibrinogenemia and evaluate whether fibrinogen replacement should have a role in the initial administration of massive transfusion. Methods: All patients <18 years of age presenting to our trauma center 11/17-4/21 were reviewed. We then evaluated all patients who received emergency-release and massive transfusion protocol (MTP) products. Patients were defined as hypofibrinogenemic (HYPOFIB) if admission fibrinogen <150 or rapid thrombelastography (r-TEG) angle <60 degrees. Our analysis sought to define risk factors for presenting with HYPOFIB, the impact on outcomes, and whether early replacement improved mortality. Results: 4169 patients were entered into the trauma registry, with 926 level 1 trauma activations, of which 186 patients received emergency-release blood products during this time; 1%, 3%, and 10% were HYPOFIB, respectively. Of the 186 patients of interest, 18 were HYPOFIB and 168 were non-HYPOFIB. The HYPOFIB patients were significantly younger, had lower field and arrival Glasgow Coma Scale, had higher head Abbreviated Injury Scale, arrived with worse global coagulopathy, and died from brain injury. Non-HYPOFIB patients were more likely to have (+)focused assessment for the sonography of trauma on arrival, sustained severe abdominal injuries, and die from hemorrhage. 12% of patients who received early cryoprecipitate (0-2 hours) had higher mortality by univariate analysis (55% vs 31%, p=0.045), but no difference on multivariate analysis (OR 0.36, 95% CI 0.07 to 1.81, p=0.221). Those receiving early cryoprecipitate who survived after pediatric intensive care unit (PICU) admission had lower PICU fibrinogen and r-TEG alpha-angle values. Conclusion: In pediatric trauma, patients with hypofibrinogenemia on admission are most likely younger and to have sustained severe brain injury, with an associated mortality of over 80%. Given the absence of bleeding-related deaths in HYPOFIB patients, this study does not provide evidence for the empiric use of cryoprecipitate in the initial administration of a massive transfusion protocol. Level of Evidence: Level III - Therapeutic/Care Management.
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Policies embracing circular economy concepts have taken hold in national legislation around the world. As the number of governments and organizations adopting circular economy policies increases, so does the need for accurate and timely measurement of material resource flows. Since many countries do not have access to centrally reported municipal solid waste (MSW) data, estimation and modeling are critical in evaluating circular economy policy effectiveness. The purpose of this paper is to examine three modeling approaches estimating national MSW data in the United States, including industry-based material flow analysis, waste-extended input-output modeling, and aggregated regional waste reporting. We establish five criteria to guide the analysis through the context of policy monitoring (data quality, flow totality, update frequency, sensitivity to disruption, and product granularity) and use these criteria to analyze and score each model. We then use a literature search to identify five, internationally-implemented options for circular economy policy and determine the data and modeling components that are most helpful in evaluating policy effectiveness. Finally, we provide a crosswalk of the model scores and policy needs to inform the suitability of model selection by policy type. We found that data quality and update frequency are identified as critical components for evaluating circular economy policies within the models evaluated, and can both be fulfilled by aggregated regional waste reporting. Flow totality, sensitivity to disruption, and product granularity requirements vary by both model and policy types. While none of the evaluated models satisfy the combination of requirements for any of the five policies, industry-based material flow analysis offers flow totality for extended producer responsibility, landfill bans, and recycling rate target policies that typically require it. The waste-extended input-output model can provide disruption sensitivity and product granularity as needed for policies like minimum recycled content and market restrictions. Policy developers in areas where strong centralized data collection is not an option should design policy action(s) with modeling tradeoffs in mind, including the potential hybridization of modeling approaches that may provide the most accurate national MSW estimates.
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The case of a 24-year-old female patient with hereditary angioedema, a normal C1 esterase inhibitor level, SLE, and pregnancy is reported.
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Agile rf sources are a common requirement for control systems in quantum science and technology platforms. The direct digital synthesizer (DDS) often fills this role by allowing programmable control of the rf signals. Due to limitations of the DDS architecture, implementing an agile rf source requires rapid and precisely-timed programming of discrete updates that restrict the source's agility. Here, we describe a microcontroller-based interface that exploits the DDS's internal linear sweep accumulator to perform both sequential linear sweeps and standard discrete updates at the â¼10µs scale. This allows updates to the swept parameter as fast as every 8 ns with greatly reduced communication and memory overhead. We demonstrate the utility of this system by using it as the reference of an optical phase-locked loop to implement rapid, adjustable laser frequency sweeps in a Rydberg electromagnetically induced transparency spectroscopy measurement.
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BACKGROUND: Congenital heart defects are the most common and resource-intensive birth defects. As children with congenital heart defects increasingly survive beyond early childhood, it is imperative to understand longitudinal disease burden. OBJECTIVES: The purpose of this study was to examine chronic outpatient prescription medication use and expenditures for New York State pediatric Medicaid enrollees, comparing children who undergo cardiac surgery (cardiac enrollees) and the general pediatric population. METHODS: This was a retrospective cohort study of all Medicaid enrollees age <18 years using the New York State Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources database (2006-2019). Primary outcomes were total chronic medications per person-year, enrollees per 100 person-years using ≥1 and ≥3 medications, and medication expenditures per person-year. We described and compared outcomes between cardiac enrollees and the general pediatric population. Among cardiac enrollees, multivariable regression examined associations between outcomes and clinical characteristics. RESULTS: We included 5,459 unique children (32,131 person-years) who underwent cardiac surgery and 4.5 million children (22 million person-years) who did not. More than 4 in 10 children who underwent cardiac surgery used ≥1 chronic medication compared with approximately 1 in 10 children who did not have cardiac surgery. Medication expenditures were 10 times higher per person-year for cardiac compared with noncardiac enrollees. Among cardiac enrollees, disease severity was associated with chronic medication use; use was highest among infants; however, nearly one-half of adolescents used ≥1 chronic medication. CONCLUSIONS: Children who undergo cardiac surgery experience high medication burden that persists throughout childhood. Understanding chronic medication use can inform clinicians (both pediatricians and subspecialists) and policymakers, and ultimately the value of care for this medically complex population.