Provider Perspectives of Transitions of Care at a Tertiary Care Children's Hospital With a Hospitalist-Run Discharge Clinic.

Children's hospitals are discharging patients to home with increasingly complex outpatient needs, making safe transitions of care (ToCs) of vital importance. Our study involved a survey of both outpatient providers and pediatric hospitalists associated with our medical center to better describe providers' views on the ToC process. The survey included questions assessing views on patient care responsibilities, resource availability, our hospitalist-run postdischarge clinic (PDC), and comfort with telemedicine. Our hospitalists generally believed that primary care providers (PCPs) did not have adequate access to important ToC elements, whereas PCPs felt their access was adequate. Both provider types felt it was the inpatient team's responsibility to manage patient events between discharge and PCP follow-up and that a hospitalist-run PDC may reduce interim emergency room visits. This study challenges perceptions about the ToC process in children and describes a generalizable approach to assessing provider perceptions surrounding the ToC within individual health systems.

Integrating basic and applied research to estimate carnivore abundance.

A clear connection between basic research and applied management is often missing or difficult to discern. We present a case study of integration of basic research with applied management for estimating abundance of gray wolves (Canis lupus) in Montana, USA. Estimating wolf abundance is a key component of wolf management but is costly and time intensive as wolf populations continue to grow. We developed a multimodel approach using an occupancy model, mechanistic territory model, and empirical group size model to improve abundance estimates while reducing monitoring effort. Whereas field-based wolf counts generally rely on costly, difficult-to-collect monitoring data, especially for larger areas or population sizes, our approach efficiently uses readily available wolf observation data and introduces models focused on biological mechanisms underlying territorial and social behavior. In a three-part process, the occupancy model first estimates the extent of wolf distribution in Montana, based on environmental covariates and wolf observations. The spatially explicit mechanistic territory model predicts territory sizes using simple behavioral rules and data on prey resources, terrain ruggedness, and human density. Together, these models predict the number of packs. An empirical pack size model based on 14 years of data demonstrates that pack sizes are positively related to local densities of packs, and negatively related to terrain ruggedness, local mortalities, and intensity of harvest management. Total abundance estimates for given areas are derived by combining estimated numbers of packs and pack sizes. We estimated the Montana wolf population to be smallest in the first year of our study, with 91 packs and 654 wolves in 2007, followed by a population peak in 2011 with 1252 wolves. The population declined ~6% thereafter, coincident with implementation of legal harvest in Montana. Recent numbers have largely stabilized at an average of 191 packs and 1141 wolves from 2016 to 2020. This new approach accounts for biologically based, spatially explicit predictions of behavior to provide more accurate estimates of carnivore abundance at finer spatial scales. By integrating basic and applied research, our approach can therefore better inform decision-making and meet management needs.

Testing of a mobile heating facility to sanitize N-95 respirators against an enveloped respiratory virus.

In the spring of 2020, the Alaska Native Tribal Health Consortium (ANTHC) designed and built a sanitizing treatment system to address shortages of filtering facepiece respirators (FFRs). The design criteria included sanitizing large numbers of FFRs, repeatedly achieving FFR fit test requirements, and deactivating enveloped respiratory viruses, such as SARS-CoV-2. The outcome was the Mobile Sanitizing Trailer (MST), a 20 by 8-foot modified trailer designed to process up to 1,000 FFRs during a standard heat cycle. This paper reports on the MST's ability to: (1) sustain a target temperature, (2) produce tolerable conditions for FFRs as measured by fit factor and (3) successfully deactivate an infectious model virus. We found that the MST reliably and uniformly produced 75 degrees Celsius in the treatment chamber for the prescribed periods. Quantitative analysis showed that the FFRs achieved acceptable post-treatment fit factor even after 18, 60-minute heat cycles. Finally, the treated FFR materials had at least a log 3.0 reduction in viral RNA and no viable virus after 30, 60 or 90 minutes of heat treatment. As a sanitizing treatment during supply shortages, we found the MST a viable option for deactivation of virus and extending the usable life of FFRs.

Evidence of economical territory selection in a cooperative carnivore.

As an outcome of natural selection, animals are probably adapted to select territories economically by maximizing benefits and minimizing costs of territory ownership. Theory and empirical precedent indicate that a primary benefit of many territories is exclusive access to food resources, and primary costs of defending and using space are associated with competition, travel and mortality risk. A recently developed mechanistic model for economical territory selection provided numerous empirically testable predictions. We tested these predictions using location data from grey wolves (Canis lupus) in Montana, USA. As predicted, territories were smaller in areas with greater densities of prey, competitors and low-use roads, and for groups of greater size. Territory size increased before decreasing curvilinearly with greater terrain ruggedness and harvest mortalities. Our study provides evidence for the economical selection of territories as a causal mechanism underlying ecological patterns observed in a cooperative carnivore. Results demonstrate how a wide range of environmental and social conditions will influence economical behaviour and resulting space use. We expect similar responses would be observed in numerous territorial species. A mechanistic approach enables understanding how and why animals select particular territories. This knowledge can be used to enhance conservation efforts and more successfully predict effects of conservation actions.

Environmental Health Consults in Children Hospitalized with Respiratory Infections.

Indoor air pollutants contribute to respiratory infections and asthma exacerbations in children. Rural Alaska Native children experience some of the highest U.S. rates of respiratory hospitalizations, which are associated with lack of in-home running water, household crowding, and woodstove use. In our previous study, in-home education and modifications reduced respiratory symptoms, and medical visits. In this study, we evaluated the feasibility of providing in-hospital environmental health consults for parents/guardians of children < 5 years old hospitalized at the Alaska Native Medical Center with respiratory infections or asthma. Environmental health specialists conducted 92 in-hospital consults and mailed Healthy Homes Toolkits to households. Local housing authorities completed low-cost home modifications in 47 eligible households. Participants reported changes in household behaviors that were specifically addressed in the consult or included in the Toolkit (e.g. allergen-impermeable pillow covers). Reported respiratory symptoms were decreased at the 6-month follow-up. Over a 2 year period the median overall medical costs for respiratory illness in study children were $70,500. Children with in-home piped water had half the daily overall medical costs than children without in-home piped water ($74 compared to $144). In this study, we demonstrate that it is feasible to provide environmental consults, mail Toolkits, and arrange home modifications to the homes of children hospitalized with respiratory illness. These findings, along with the high costs of medical care for these children, suggest in-hospital environmental health consults are a cost-effective intervention.

Orientation in Perpetuity: An Online Clinical Decision Support System for Surgical Residents.

BACKGROUND: Limiting variability is an essential element to improving quality of care. Frequent resident turnover represents a significant barrier to clinical standardization. Trainees joining new surgical services must familiarize themselves with the guidelines and protocols that direct patient care as well as their learning objectives and expectations. A clinical decision support system (CDSS) is a dynamic, searchable electronic resource intended for use at the point of care. The CDSS can provide convenient and timely access to relevant information for residents, allowing them to incorporate the most up-to-date protocols and guidelines in their daily care of patients. The objective of this quality improvement intervention was to determine the objective rate of CDSS utilization and its subjective value to residents. MATERIALS AND METHODS: An internally developed, web-based CDSS including essential, clinically useful documents was created for use by trainees on a busy pediatric surgery service. A standardized orientation was provided to each resident and fellow on joining the service, complemented by a summary card to be attached to the trainee's ID badge. CDSS usage was monitored using web analytics. Trainees who rotated before and after the CDSS launch were surveyed regarding attitudes toward clinical resources and confidence in patient management. RESULTS: Documents published to the CDSS included 33 clinical guideline documents and 207 additional educational and support files including reference materials from service orientation were made available to trainees and staff. Goals for resident usage were established by evaluation and adaptation of early traffic patterns. Analysis of web traffic collected over 14 consecutive months revealed utilization above target levels, with 4.0 average weekly page views per trainee (IQR: 1.6-5.6). A total of 60 survey responses were received (54% of trainees invited); majorities of rotating trainees and survey respondents were trainees in general surgery and most were interns. Mean composite scores reflected a trend toward improved satisfaction when seeking CDSM (before intervention 3.18 [SD 0.73], after intervention 3.92 [SD 0.70], range 1-5) which was statistically significant (P = 0.005). Mean scores also improved across five of six components of the composite score (mean improvement 0.75, range: 0.53-0.92), four of which were statistically significant (P = 0.001-0.038). Most (59%) respondents reported that they used the CDSS frequently. CONCLUSIONS: Convenient access to a CDSS resulted in greater than expected utilization as well as higher resident satisfaction with and confidence in materials provided. A CDSS is a promising tool offering quick access to high-quality information in challenging trainee environments.

Themes Depicted in Running-Related Films: An Opportunity for Co-Viewing and Active Mediation.

Sport participation is an important part of the development of children and adolescents. The objective of this study was to identify and quantify themes depicted in a select number of running-related films. Thirty-one running-related films were independently viewed and analyzed by 4 reviewers. The number of positive and negative themes was 29.5 (95% confidence interval = 26.1-33.4) and 9.0 (95% confidence interval = 7.9-10.2) mean events per hour for all included films, respectively. The most common positive themes were "overcoming physical limitations," "overcoming mental obstacles," and "encouragement from family/friends/fans" (2.6, 2.4, and 2.3 mean events per hour, respectively). The most common negative themes were "giving up/losing confidence," "ignoring injuries," and "discouragement/ridicule from coach/athletic trainer" (1.2, 1.1, and 0.66 mean events per hour, respectively). In conclusion, the co-viewing of running-related films with pediatric athletes in order to focus on "teachable moments" may encourage the acquisition and development of positive themes and the avoidance and de-emphasis of negative themes.

Injury and Illness Depicted in Running-Related Films.

The perception that children and adolescents have of injury and illness may be influenced by their depiction in sport-related films. The objective of this study was to determine the depiction of injury and illness in a select number of running-related films. A sample of 31 running-related films were analyzed, with a total of 77 injuries/illnesses depicted. The most common injuries/illnesses depicted were categorized as exertional heat exhaustion/stroke (26%), lower leg muscle cramps/not heat related (12%), ankle sprain (9%), knee ligamentous/meniscus injury (6%), exercise-associated collapse/not heat related (6%), and blister of the toe/foot (6%). Overall, 48/67 (64%) of the injuries/illnesses were considered severe emergencies (injury/illness requiring prompt intervention and immediate discontinuation of sport participation). The disposition of 46% of severe emergencies was the immediate continuation of training/competition. Pediatric health care providers, coaching staff, and parents should stress the importance of injury/illness recognition/disclosure and realistic expectations for rehabilitation to pediatric runners.

Emergency Department and Primary Care Use by Refugees Compared to Non-refugee Controls.

The U.S. grants asylum to 60,000-70,000 refugees yearly. However, little is known about their healthcare utilization practices. We examined data from emergency department (ED) and primary care (PC) visits of 694 refugees and 738 non-refugee controls over a 3 years period at a large academic medical center, comparing visit frequencies, Emergency Severity Index (ESI) scores, diagnoses, and dispositions. Refugees used emergency care services less frequently than the non-refugee controls (1.19 vs. 2.31, p < 0.0001) while there was no difference in their use of primary care services (8.45 vs. 9.07, p = 0.18). Non-English-speaking refugees were more likely to use the ED than English-speaking refugees (mean ED use in study period 1.50 visits vs. 0.73, p < 0.0001). Refugee patients utilized emergency services less often compared to controls. These results differ from previously studied refugee populations. Refugee-specific primary care services in this study population may reduce unnecessary ED use.

Animal migration amid shifting patterns of phenology and predation: lessons from a Yellowstone elk herd.

Migration is a striking behavioral strategy by which many animals enhance resource acquisition while reducing predation risk. Historically, the demographic benefits of such movements made migration common, but in many taxa the phenomenon is considered globally threatened. Here we describe a long-term decline in the productivity of elk (Cervus elaphus) that migrate through intact wilderness areas to protected summer ranges inside Yellowstone National Park, USA. We attribute this decline to a long-term reduction in the demographic benefits that ungulates typically gain from migration. Among migratory elk, we observed a 21-year, 70% reduction in recruitment and a 4-year, 19% depression in their pregnancy rate largely caused by infrequent reproduction of females that were young or lactating. In contrast, among resident elk, we have recently observed increasing recruitment and a high rate of pregnancy. Landscape-level changes in habitat quality and predation appear to be responsible for the declining productivity of Yellowstone migrants. From 1989 to 2009, migratory elk experienced an increasing rate and shorter duration of green-up coincident with warmer spring-summer temperatures and reduced spring precipitation, also consistent with observations of an unusually severe drought in the region. Migrants are also now exposed to four times as many grizzly bears (Ursus arctos) and wolves (Canis lupus) as resident elk. Both of these restored predators consume migratory elk calves at high rates in the Yellowstone wilderness but are maintained at low densities via lethal management and human disturbance in the year-round habitats of resident elk. Our findings suggest that large-carnivore recovery and drought, operating simultaneously along an elevation gradient, have disproportionately influenced the demography of migratory elk. Many migratory animals travel large geographic distances between their seasonal ranges. Changes in land use and climate that disparately influence such seasonal ranges may alter the ecological basis of migratory behavior, representing an important challenge for, and a powerful lens into, the ecology and conservation of migratory taxa.

Faunal isotope records reveal trophic and nutrient dynamics in twentieth century Yellowstone grasslands.

Population sizes and movement patterns of ungulate grazers and their predators have fluctuated dramatically over the past few centuries, largely owing to overharvesting, land-use change and historic management. We used δ(13)C and δ(15)N values measured from bone collagen of historic and recent gray wolves and their potential primary prey from Yellowstone National Park to gain insight into the trophic dynamics and nutrient conditions of historic and modern grasslands. The diet of reintroduced wolves closely parallels that of the historic population. We suggest that a significant shift in faunal δ(15)N values over the past century reflects impacts of anthropogenic environmental changes on grassland ecosystems, including grazer-mediated shifts in grassland nitrogen cycle processes.

Elk migration patterns and human activity influence wolf habitat use in the Greater Yellowstone Ecosystem.

Identifying the ecological dynamics underlying human-wildlife conflicts is important for the management and conservation of wildlife populations. In landscapes still occupied by large carnivores, many ungulate prey species migrate seasonally, yet little empirical research has explored the relationship between carnivore distribution and ungulate migration strategy. In this study, we evaluate the influence of elk (Cervus elaphus) distribution and other landscape features on wolf (Canis lupus) habitat use in an area of chronic wolf-livestock conflict in the Greater Yellowstone Ecosystem, USA. Using three years of fine-scale wolf (n = 14) and elk (n = 81) movement data, we compared the seasonal habitat use of wolves in an area dominated by migratory elk with that of wolves in an adjacent area dominated by resident elk. Most migratory elk vacate the associated winter wolf territories each summer via a 40-60 km migration, whereas resident elk remain accessible to wolves year-round. We used a generalized linear model to compare the relative probability of wolf use as a function of GIS-based habitat covariates in the migratory and resident elk areas. Although wolves in both areas used elk-rich habitat all year, elk density in summer had a weaker influence on the habitat use of wolves in the migratory elk area than the resident elk area. Wolves employed a number of alternative strategies to cope with the departure of migratory elk. Wolves in the two areas also differed in their disposition toward roads. In winter, wolves in the migratory elk area used habitat close to roads, while wolves in the resident elk area avoided roads. In summer, wolves in the migratory elk area were indifferent to roads, while wolves in resident elk areas strongly avoided roads, presumably due to the location of dens and summering elk combined with different traffic levels. Study results can help wildlife managers to anticipate the movements and establishment of wolf packs as they expand into areas with migratory or resident prey populations, varying levels of human activity, and front-country rangelands with potential for conflicts with livestock.