Economic risks hidden in local water pollution and global markets: A retrospective analysis (1995-2010) and future perspectives on sustainable development goal 6.

Pollution from untreated wastewater discharges depletes clean water supply for humans and the environment. It poses adverse economic impacts by determining agricultural yields, manufacturing productivity, and ecosystem functionality. Current studies mainly focus on quantity-related water scarcity assessment. It is unknown how low water quality amplifies local water stress and induces cascading economic risks globally. In this study, we estimated both quality and quantity-related water scarcity index (WSI), local economic water scarcity risk (WSR), and cascading virtual WSR evident in global trade markets across 40 major economies from 1995 to 2010. We find developing countries, e.g., India and China, witnessed fast growth in both quantity and quality-related WSI. Major developed economies, e.g., the US and Germany, experienced a modest increase in water stress but alleviated quality-related risks. Local economic risk (WSR) grew from $116B to $380B, with quality-related risks rising from 20 % to 30 %. Virtual economic WSR in global supply chains increased from $39B to $160B, with quality-related risks increasing from 19 % to 27 %. China became the top exporter of economic WSR, ranked above the US, France, and Japan, and the second-largest position as an importer, trailing only the US. We finally conducted scenario modeling by 2030, assuming different progresses on SDG 6 targets. The findings suggest that only the most ambitious progress in both water quality enhancement and efficiency improvement helps to alleviate ∼20 % economic WSR globally. Our findings underscore the necessity for strategies that integrate management of untreated wastewater flows, improved water use efficiency, and diversification of supply chain networks to enhance global economic resilience to water challenges in the future.

Internet-Based Cognitive-Behavioral Therapy for College Students With Anxiety, Depression, Social Anxiety, or Insomnia: Four Single-Group Longitudinal Studies of Archival Commercial Data and Replication of Employee User Study.

BACKGROUND: The growing behavioral health needs of college students have resulted in counseling centers reporting difficulties in meeting student demand. OBJECTIVE: This study aims to test the real-world voluntary use by college students of 4 digital, self-directed mental health modules based on a cognitive behavioral therapy clinical model. The findings were also compared with those of employee users. METHODS: Archival operational data from Learn to Live were extracted for student users at 4 colleges and universities in the Midwest region of the United States (N=951). The inclusion criteria were having clinical symptoms at established levels of moderate or higher severity and the use of 2 or more of the 8 lessons of a program within a 6-month period. Unique users in each program included 347 for depression; 325 for stress, anxiety, and worry; 203 for social anxiety; and 76 for insomnia. Paired t tests (two-tailed) compared the average level of change over time on a standardized measure of clinical symptoms appropriate to each program. Cohen d statistical effect sizes were calculated for each program. Potential moderator factors (age, gender, preliminary comprehensive assessment, number of lessons, duration, live coach support, and live teammate support) were tested together in repeated measures analysis of variance models with covariates in the full sample. Follow-up survey data (n=136) were also collected to explore user satisfaction and outcomes. Select data from another study of the same 4 programs by employee users meeting the same criteria (N=707) were examined for comparison. RESULTS: The percentage of users who improved to a clinical status of no longer being at risk after program use was as follows: stress, anxiety, and worry program (149/325, 45.8%); insomnia program (33/76, 43.4%), depression program (124/347, 35.7%); and social anxiety program (45/203, 22.2%). Significant improvements (all P<.001) over time were found in the mean scores for the clinical measures for each program: stress, anxiety, and worry (t324=16.21; d=1.25); insomnia (t75=6.85; d=1.10); depression (t346=12.71; d=0.91); and social anxiety (t202=8.33; d=0.80). Tests of the moderating factors across programs indicated that greater improvement was strongly associated with the use of more lessons and it also differed by program, by gender (males demonstrated more improvement than females), and by the use of live support (particularly coaching). Analyses of survey data found high satisfaction, improved academic outcomes, and successful integration into the university counseling ecosystem. The operational profile and outcomes of the college students were also similar to those of employee users of the same programs from our other study of employee users. Thus, this study provides a replication. CONCLUSIONS: Self-directed internet-based cognitive behavioral therapy mental health modules are promising as a supplement to traditional in-person counseling services provided by college counseling centers.

Instrument-Assisted Soft-Tissue Mobilization for the Management of Chronic Plantar Heel Pain: A Pilot Study.

BACKGROUND: The purpose of this study was to determine feasibility of further investigation of treatment with instrument-assisted soft-tissue mobilization (IASTM), using the Graston technique, compared with conservative care for treatment of chronic plantar heel pain (CPHP). METHODS: Eleven participants with plantar heel pain lasting 6 weeks to 1 year were randomly assigned to one of two groups, with each group receiving up to eight physical therapy visits. Both groups received the same stretching, exercise, and home program, but the experimental group also received IASTM using the Graston technique. Outcome measures of pain and function were recorded at baseline, after final treatment, and 90 days later. Feasibility of a larger study was determined considering recruitment and retention rates, compliance, successful application of the protocol and estimates of the treatment effect. RESULTS: Both groups demonstrated improvements in current pain (pain at time of survey), pain with the first step in the morning, and function after final treatment and at 90-day follow up. Medium-to-large effect sizes between groups were noted, and sample size estimates demonstrated a need for at least 42 participants to realize a group difference. A larger-scale study was determined to be feasible with modifications including a larger sample size and higher recruitment rate. CONCLUSIONS: This pilot study demonstrates that inclusion of IASTM using the Graston technique for CPHP lasting longer than 6 weeks is a feasible intervention warranting further study. Clinically important changes in the IASTM group and moderate-to-large between-group effect sizes suggest that further research is warranted to determine whether these trends are meaningful.

Outcomes among patients receiving in-center, self-care hemodialysis.

Modalities of renal replacement therapy are categorized into incenter hemodialysis and home therapies. A subset of hemodialysis patients referred to as in-center self-care hemodialysis (ICSCHD) receive patient training as if they were going home but instead perform their dialysis in-center with minimal staff support. Preliminary data suggests ICSCHD is associated with better outcomes than traditional in-center hemodialysis. We looked at ICSCHD patients initiating maintenance dialysis from April 1, 2011 to March 30, 2014 and compared them at a 1:2 ratio to propensity-score matched controls from surrounding facilities within the same catchment area. The median follow-up was 14 months. Patients on ICSCHD had lower mortality rate (0.02 vs 0.07 per patient year; p <0.05), fewer hospitalization events (0.82 vs. 1.70 per patient year; p = 0.008) and fewer missed treatments (1.1% vs 3.8% of all treatments; p = 0.005) than matched controls. We concluded that patients on ICSCHD had lower mortality rates and fewer hospital days than well-matched controls and spent more time on dialysis and missed fewer treatments. Establishing a facility-wide.

Managing Disruptive Behavior by Patients and Physicians: A Responsibility of the Dialysis Facility Medical Director.

The Centers for Medicare & Medicaid Services' Conditions for Coverage make the medical director of an ESRD facility responsible for all aspects of care, including high-quality health care delivery (e.g., safe, effective, timely, efficient, and patient centered). Because of the high-pressure environment of the dialysis facility, conflicts are common. Conflict frequently occurs when aberrant behaviors disrupt the dialysis facility. Patients, family members, friends, and, less commonly appreciated, nephrology clinicians (i.e., nephrologists and advanced care practitioners) may manifest disruptive behavior. Disruptive behavior in the dialysis facility impairs the ability to deliver high-quality care. Furthermore, disruptive behavior is the leading cause for involuntary discharge (IVD) or involuntary transfer (IVT) of a patient from a facility. IVD usually results in loss of continuity of care, increased emergency department visits, and increased unscheduled, acute dialysis treatments. A sufficient number of IVDs and IVTs also trigger an extensive review of the facility by the regional ESRD Networks, exposing the facility to possible Medicare-imposed sanctions. Medical directors must be equipped to recognize and correct disruptive behavior. Nephrology-based literature and tools exist to help dialysis facility medical directors successfully address and resolve disruptive behavior before medical directors must involuntarily discharge a patient or terminate an attending clinician.

Integrated renal care: are nephrologists ready for change in renal care delivery models?

The Affordable Care Act is the most visible element of health care reform. However, both before the Affordable Care Act and now with the acceleration since its passage, the Centers for Medicare and Medicaid have been and are testing integrated care models in medicine in general as well as nephrology. The pressures to do so come from the well known increasing costs of health care in the face of a number of clear gaps in quality. The future will likely be more and more integrated care with less and less fee for service. More measurement of quality and the linking of quality measures to payments are also all but certain future elements of the health care economy. Nephrologists need to educate themselves on these trends and be prepared to engage them for the good of the profession and the improvement in care for patients.

Aquaporin-11 control of testicular fertility markers in Syrian hamsters.

The present study sought novel changes to the hamster testicular transcriptome during modulation of fertility by well-characterized photoperiodic stimuli. Transition from long days (LD, 14 h light/day) to short days (SD, 10h light/day) triggered testicular regression (61% reduction of testis weight, relative to LD) in SD-sensitive (SD-S) hamsters within 16 weeks. After 22 weeks of SD exposure, a third cohort of hamsters became SD-refractory (SD-R), and exhibited testicular recrudescence (137% testis weight gain, relative to SD-S). Partial interrogation of the testicular transcriptome by annealing-control-primer-modified differential display PCR provided several candidates for regulation of testicular functions. Multiple linear regression modeling indicated the best correlation for aquaporin 11 (Aqp11) with changes in testis weight. Correlations were also strongest for Aqp11 with expression levels of reference cDNAs that control spermatogenesis (Hspa2 and Tnp2), steroidogenesis (Cox2, 3ßHsd, and Srebp2), sperm motility (Catsper1, Pgk2, and Tnp2), inflammation (Cox2), and apoptosis (Bax and Bcl2). Moreover, siRNA-mediated knockdown of testicular Aqp11 mRNA and protein reduced Hspa2 and Tnp2 mRNA levels, and it increased 3ßHsd mRNA levels. It also reduced mRNA levels for Sept12, which is a testis-specific inducer of spermatogenesis. These results suggest a central role for testicular Aqp11 signaling in the coordinate regulation of crucial components of fertility.

Unification of the voice of nephrology stakeholders.

Kidney Care Partners is a coalition made up of representatives from the entire kidney community. Its mission is to ensure that chronic kidney disease patients receive optimal care, lead quality lives, and have ready access to dialysis care. The coalition focuses on consensus building and a community-wide cooperative effort toward developing health policy in the interest of patients. Presently, end-stage renal disease care is underfunded, and factors such as an aging population and an increase in obesity are leading to increased demands on the system. Changes in reimbursement for erythropoiesis-stimulating agents will further challenge this system. Kidney Care Partners is strongly promoting health policy through the support of the Kidney Care Quality and Education Act of 2007 (HR 1193/S 691). Among their activities is the formation of the Kidney Care Quality Initiative in an effort to bring consensus to the development of usable quality measures.

Identifying highly effective psychotherapists in a managed care environment.

OBJECTIVE: To investigate the variability and stability of psychotherapists' effectiveness and the implications of this differential effectiveness for quality improvement in a managed care environment. STUDY DESIGN: Subset archival outcome data for patients receiving behavioral health treatment were divided into 2 time periods to cross-validate the treating therapists' effectiveness. After categorizing the therapists as "highly effective" and "others" during the baseline period, the stability of their individual effectiveness was cross-validated in the remaining time period. METHODS: Outcomes for 10 812 patients (76.0% adults, 24.0% children and adolescents) treated by 281 therapists were included. Patients initiated treatment between January 1999 and June 2004. Mean residual change scores obtained by multiple regression were used to adjust for differences in case mix among therapists. Raw change scores as well as mean residualized change scores were compared between the 71 psychotherapists identified as highly effective (25%) and those identified as other (remaining 75%). RESULTS: During the cross-validation period, mean differences in residualized change score between highly effective therapists and others were statistically significant (difference = 2.8; P < .001), which corresponded to an average of 53.3% more change in raw change scores with the highly effective therapists. Results could not be explained by case mix differences in diagnosis, age, sex, intake scores, prior outpatient treatment history, length of treatment, or therapist training/experience. CONCLUSION: Behavioral health outcomes for a large system of care could be significantly improved by measuring clinical outcomes and referring patients to therapists with superior outcomes.

Implementation of a feedback system in a managed care environment: what are patients teaching us?

Lessons about patient treatment response from a large-scale outcomes management project are summarized. More than 7,000 clinicians contributed outcome data. Overall, the data demonstrated that patients who have clinical levels of psychological distress and impairment showed a relatively rapid response to treatment. Furthermore, although it appears that the duration and intensity of treatment vary widely from case to case, clinicians and patients make sound judgments as to how much and what kind of treatment is appropriate. Results supported the conclusion that the most effective method to manage costs is to ensure that each patient receive effective care. There are large and stable differences in the effectiveness of clinicians, and outcomes can be improved by referring patients to effective clinicians. The data also suggested that patients who had a poor initial response to treatment eventually had positive outcomes, provided that they remained engaged in treatment. This finding suggests that outcomes can be improved by identifying at-risk patients and proactively keeping them engaged in treatment.