Implementing Interconception Care in a Dyadic Adolescent Mother-Child Clinic.

INTRODUCTION: The birth of a second child to an adolescent woman worsens the adverse medical, socioeconomic, educational, and parenting outcomes for the woman and her children. Despite the known high efficacy of long-acting reversible contraception (LARC), many postpartum adolescents use less effective or no contraception. Interconception care (ICC) focuses on modifying maternal risks between pregnancies and promoting healthy birth spacing to improve outcomes for women and children. Research shows that women regularly attend their child's health care visits even if they do not seek care for themselves between pregnancies. These visits present a potential opportunity for providers to educate women on available LARC options. METHODS: In an adolescent mother-child clinic, demographic and ICC screening data were collected on women presenting for well child visits of children age 0-24 months. These data were analyzed using logistic regression models to identify independent predictors of LARC initiation and repeat pregnancy. RESULTS: Mother-child dyads were screened an average of two times in the study period. Participants with only one visit were less likely to initiate LARC. Of the participants, 5.5% became pregnant again, with patients having only one ICC visit being slightly, but not significantly more likely. Hispanic ethnicity and having ≥ 2 visits were significant independent predictors of LARC initiation. The only independent predictor of repeat pregnancy was not initiating LARC. CONCLUSIONS: This study suggests that optimal ICC may rely on consistent and frequent touch points with providers and not solely on the medical management during the interconception period, making it adaptable to a traditional pediatric medical home. Tying the worlds of pediatric and maternal healthcare is pivotal for successful ICC.

Application of motional Stark effect in situ background correction to a superconducting tokamak.

A polychrometer-type motional Stark effect (MSE) diagnostic technique, originally developed for the Alcator C-Mod tokamak, has been extended and applied to the Korea Superconducting Advanced Tokamak Research (KSTAR) device, the long-pulse superconducting tokamak, for the first time. It demonstrates a successful in situ subtraction of the polarized reflections off the vacuum vessel wall, sometimes up to half the total signal in some sightlines. To avoid the secondary neutral beam emission that may contaminate conventional beam-into-gas calibrations, a new approach, where the beam-into-gas measurements are made at various torus pressures with fixed vacuum fields, has been devised, which is possible with the stable superconducting coil systems of KSTAR. The validity of this new calibration scheme has been checked via plasma jog experiments. The experimental evidence of the polarized background light and the necessity of its correction in the MSE measurements made in KSTAR are presented as well.

Influence of electronic triage decision-support on hospital admission, left without being seen and time to physician initial assessment in the emergency department.

OBJECTIVE: To explore the impact of the implementation of eCTAS, a real-time electronic decision-support tool, on hospital admission, rate of left without being seen, and time from triage to physician initial assessment. METHODS: We conducted a cohort study using population-based administrative data from all Ontario emergency departments (EDs) that had implemented eCTAS for 9 months. We compared 6 months post-eCTAS data to the same 6 months the previous year (pre-eCTAS). We included triage encounters of adult (≥ 18 years) patients if they had one of 16 pre-specified, high-volume presenting complaints. Multivariable logistic regression and quantile regression models informed the effect of eCTAS on outcomes. RESULTS: We included data from 354,176 triage encounters from 31 EDs. There was a change in the distribution of triage scores post-eCTAS, with fewer patients classified as CTAS 2 and CTAS 3, and more patients classified as CTAS 1 and CTAS 4. Overall, hospital admission decreased post-eCTAS (adjusted OR: 0.98; 95% CI: 0.97 to 1.00), with fewer CTAS 2 and more CTAS 3 and CTAS 4 patients admitted post-eCTAS. The rate of left without being seen increased (2.8% vs. 3.0%; adjusted OR: 1.07; 95% CI: 1.03 to 1.11) post-eCTAS, while time to physician initial assessment proved similar pre and post-eCTAS. CONCLUSIONS: eCTAS implementation had little impact on admission, rate of left without being seen and time to physician initial assessment. eCTAS appears to reclassify patients from higher to lower acuity scores, resulting in higher admission rates for CTAS 3 and CTAS 4 patients. It remains unknown if this reclassification is appropriate.

RéSUMé: OBJECTIF: Étudier l'impact de la mise en œuvre de l'eCTAS, un outil électronique d'aide à la décision en temps réel, sur l'admission à l'hôpital, le taux de personnes qui ne sont pas vues et le délai entre le triage et l'évaluation initiale du médecin. LES MéTHODES: Nous avons mené une étude de cohorte en utilisant les données administratives basées sur la population de tous les services d'urgence (SU) de l'Ontario qui avaient mis en place l'eCTAS depuis 9 mois. Nous avons comparé les données de six mois après l'eCTAS aux mêmes données de six mois de l'année précédente (avant l'eCTAS). Nous avons inclus les rencontres de triage des patients adultes (≥ 18 ans) s'ils présentaient l'une des 16 plaintes pré-spécifiées à haut volume. Des modèles de régression logistique multivariable et de régression quantile ont permis d'évaluer l'effet de l'eCTAS sur les résultats. RéSULTATS: Nous avons inclus les données de 354 176 rencontres de triage provenant de 31 services d'urgence. Il y a eu un changement dans la distribution des scores de triage après l'eCTAS, avec moins de patients classés comme CTAS 2 et CTAS 3, et plus de patients classés comme CTAS 1 et CTAS 4. Dans l'ensemble, les admissions à l'hôpital ont diminué après l'eCTAS (RC ajusté: 0,98 ; 95 % IC 0,97 à 1,00), avec moins de patients CTAS 2 et plus de patients CTAS 3 et CTAS 4 admis après eCTAS. Le taux de personnes laissées sans surveillance a augmenté (2,8 % contre 3,0 % ; RC ajusté : 1,07 ; 95 % IC 1,03 à 1,11) après l'eCTAS, tandis que le délai avant l'évaluation initiale par le médecin s'est avéré similaire avant et après l'eCTAS. CONCLUSIONS: La mise en œuvre de l'eCTAS a eu peu d'impact sur l'admission, le taux de patients laissés sans consultation et le temps nécessaire à l'évaluation initiale par le médecin. L'eCTAS semble reclasser les patients des scores d'acuité supérieurs aux scores d'acuité inférieurs, ce qui entraîne des taux d'admission plus élevés pour les patients CTAS 3 et CTAS 4. On ignore encore si ce reclassement est approprié.

Consistency of triage scores by presenting complaint pre- and post-implementation of a real-time electronic triage decision support tool.

OBJECTIVE: eCTAS is a real-time electronic decision-support tool designed to standardize the application of the Canadian Triage and Acuity Scale (CTAS). This study addresses the variability of CTAS score distributions across institutions pre- and post-eCTAS implementation. METHODS: We used population-based administrative data from 2016-2018 from all emergency departments (EDs) that had implemented eCTAS for 9 months. Following a 3-month stabilization period, we compared 6 months post-eCTAS data to the same 6 months the previous year (pre-eCTAS). We included triage encounters of adult (≥17 years) patients who presented with 1 of 16 pre-specified, high-volume complaints. For each ED, consistency was calculated as the absolute difference in CTAS distribution compared to the average of all included EDs for each presenting complaint. Pre-eCTAS and post-eCTAS change scores were compared using a paired-samples t-test. We also assessed if eCTAS modifiers were associated with triage consistency. RESULTS: There were 363,214 (183,231 pre-eCTAS, 179,983 post-eCTAS) triage encounters included from 35 EDs. Triage scores were more consistent (P < 0.05) post-eCTAS for 6 (37.5%) presenting complaints: chest pain (cardiac features), extremity weakness/symptoms of cerebrovascular accident, fever, shortness of breath, syncope, and hyperglycemia. Triage consistency was similar pre- and post-eCTAS for altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication, and vertigo. Use of eCTAS modifiers was associated with increased triage consistency. CONCLUSIONS: eCTAS increased triage consistency across many, but not all, high-volume presenting complaints. Modifier use was associated with increased triage consistency, particularly for non-specific complaints such as fever and general weakness.

Interrater Reliability, Accuracy, and Triage Time Pre- and Post-implementation of a Real-Time Electronic Triage Decision-Support Tool.

STUDY OBJECTIVE: The electronic Canadian Triage and Acuity Scale (eCTAS) is a real-time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The objective of this study is to determine interrater agreement of triage scores pre- and post-implementation of eCTAS. METHODS: This was a prospective, observational study conducted in 7 emergency departments (EDs), selected to represent a mix of triage documentation practices, hospital types, and patient volumes. A provincial CTAS auditor observed triage nurses in the ED pre- and post-implementation of eCTAS and assigned an independent CTAS score in real time. Research assistants independently recorded triage time. Interrater agreement was estimated with κ statistics with 95% confidence intervals (CIs). RESULTS: A total of 1,491 individual triage assessments (752 pre-eCTAS, 739 post-implementation) were audited during 42 7-hour triage shifts (21 pre-eCTAS, 21 post-implementation). Exact modal agreement was achieved for 567 patients (75.4%) pre-eCTAS compared with 685 patients (92.7%) triaged with eCTAS. With the auditor's CTAS score as the reference, eCTAS significantly reduced the number of patients over-triaged (12.0% versus 5.1%; Δ 6.9; 95% CI 4.0 to 9.7) and under-triaged (12.6% versus 2.2%; Δ 10.4; 95% CI 7.9 to 13.2). Interrater agreement was higher with eCTAS (unweighted κ 0.89 versus 0.63; quadratic-weighted κ 0.93 versus 0.79). Median triage time was 312 seconds (n=3,808 patients) pre-eCTAS and 347 seconds (n=3,489 patients) with eCTAS (Δ 35 seconds; 95% CI 29 to 40 seconds). CONCLUSION: A standardized, electronic approach to performing triage assessments improves both interrater agreement and data accuracy without substantially increasing triage time.

Unique Features of the US Department of Defense Multidisciplinary Concussion Clinics.

The US Department of Defense (DoD) and the Department of Veterans Affairs (VA) actively address care needs for a subset of service members (SMs) who experience prolonged symptoms and adverse sequelae interfering with their usual level of function after sustaining mild traumatic brain injury. The development of multidisciplinary concussion clinics and implementation of several reinforcing policies within the DoD and the VA address this unique patient population. A network known as the National Intrepid Center of Excellence and Intrepid Spirit Centers and the VA, primarily support these patients through intensive outpatient programs. The VA also has an inpatient program that utilizes specialized capabilities. The features unique to several of these centers are described in this article. While providing for similar patient care needs, each clinical setting implements unique evaluation and treatment modalities to target analogous goals of return to the highest functional level possible and develop life skills to enhance health, quality of life, and readiness to perform military duties. Currently, patient-reported outcomes are being collected.

Development of the Diabetes Technology Society Blood Glucose Monitor System Surveillance Protocol.

BACKGROUND: Inaccurate blood glucsoe monitoring systems (BGMSs) can lead to adverse health effects. The Diabetes Technology Society (DTS) Surveillance Program for cleared BGMSs is intended to protect people with diabetes from inaccurate, unreliable BGMS products that are currently on the market in the United States. The Surveillance Program will provide an independent assessment of the analytical performance of cleared BGMSs. METHODS: The DTS BGMS Surveillance Program Steering Committee included experts in glucose monitoring, surveillance testing, and regulatory science. Over one year, the committee engaged in meetings and teleconferences aiming to describe how to conduct BGMS surveillance studies in a scientifically sound manner that is in compliance with good clinical practice and all relevant regulations. RESULTS: A clinical surveillance protocol was created that contains performance targets and analytical accuracy-testing studies with marketed BGMS products conducted by qualified clinical and laboratory sites. This protocol entitled "Protocol for the Diabetes Technology Society Blood Glucose Monitor System Surveillance Program" is attached as supplementary material. CONCLUSION: This program is needed because currently once a BGMS product has been cleared for use by the FDA, no systematic postmarket Surveillance Program exists that can monitor analytical performance and detect potential problems. This protocol will allow identification of inaccurate and unreliable BGMSs currently available on the US market. The DTS Surveillance Program will provide BGMS manufacturers a benchmark to understand the postmarket analytical performance of their products. Furthermore, patients, health care professionals, payers, and regulatory agencies will be able to use the results of the study to make informed decisions to, respectively, select, prescribe, finance, and regulate BGMSs on the market.

Cryptolepiota, a new sequestrate genus in the Agaricaceae with evidence for adaptive radiation in western North America.

Phylogenetic analyses based on nLSU and ITS sequence data indicate that the sequestrate genus Gigasperma is polyphyletic. Gigasperma cryptica, which is known only from New Zealand, has affinities with the Cortinariaceae whereas G. americanum and two additional undescribed taxa from western North America are derived from Lepiota within the Agaricaceae. The three North American taxa appear to be recently evolved and are closely related. They occur in similar environments and form a well supported clade indicating that adaptive radiation has occurred within this group of fungi. An independent genus with sequestrate fructifications, Cryptolepiota is proposed to accommodate the three species in this clade. Cryptolepiota microspora and C. mengei are described as new, and G. americanum is transferred to Cryptolepiota. Gigasperma cryptica is illustrated and compared with the species of Cryptolepiota.

A robust microfluidic in vitro cell perifusion system.

We present here a robust microfluidic cell perifusion device for in vitro primary tissue cell secretion studies. This system increases the sample concentration to perifusion volume ratio by an order of magnitude compared with standard multi-well plate static incubation assays. Further, this device achieves physiologically relevant flow rates, pressures, and temperature. It has been manufactured with typical machining facilities, principally drilling and milling. No specialist clean room equipment is required to replicate it. We show its capability here with hormone perifusion experiments on primary pancreatic tissue from mice. This device can increase cell secretion concentrations by up to a factor of 20, allowing for the first time the direct measurement of islet glucagon using mass spectrometry.

Intrashot motional Stark effect calibration technique for lower hybrid current drive experiments.

The spurious drift in pitch angle of order several degrees measured by the motional Stark effect (MSE) diagnostic in the Alcator C-Mod tokamak over the course of an experimental run day has precluded direct utilization of independent absolute calibrations. Recently, the underlying cause of the drift has been identified as thermal stress-induced birefringence in a set of in-vessel lenses. The shot-to-shot drift can be avoided by using MSE to measure only the change in pitch angle between a reference phase and a phase of physical interest within a single plasma discharge. This intrashot calibration technique has been applied to the lower hybrid current drive (LHCD) experiments and the measured current profiles qualitatively demonstrate several predictions of LHCD theory such as an inverse dependence of current drive efficiency on the parallel refractive index and the presence of off-axis current drive.

International partnerships to foster growth in emergency medicine in Romania.

Emergency medicine (EM) is a growing specialty internationally, but has yet to be cultivated in countries with otherwise advanced health care systems. To promote the growth of EM, emergency physicians from countries where EM is a mature specialty can assist with knowledge transfer and development of emergency medical systems to make a lasting impact on the community served. We present our experience in assisting the development of emergency medicine in a university-affiliated regional hospital in Romania. The International Emergency Medicine Fellowship program at the University of Toronto established links in Cluj-Napoca, Romania, in order to provide expertise and assist local leadership to stimulate growth in EM. In October 2005, a 3-member team travelled to Cluj-Napoca to provide input on how to best use a new physical plant, to deliver continuing education to physicians and nurses, and to help establish long-term development goals. The team identified the following priorities through a comprehensive needs assessment: physical plant organization and patient flow, staffing, staff education, equipment, medication and supplies, and infection control practices. In conjunction with local counterparts, a plan was developed addressing each priority. Staff, hospital administration and university officials report positive growth in EM as a result of the collaboration. Further work is underway to implement the plan, including international exchange trips to promote mutual growth between partners.

The influence of reaction temperature on the oscillatory behaviour in the palladium-catalysed phenylacetylene oxidative carbonylation reaction.

This paper reports the influence of reaction temperature on the occurrence and characteristics of pH oscillations that are observed during the palladium-catalysed phenylacetylene oxidative carbonylation reaction in a catalytic system (PdI2, KI, air, NaOAc) in methanol. Isothermal experiments were performed over the temperature range 10-50 degrees C. The experiments demonstrate that oscillations occur in the range 10-40 degrees C and that a decrease in reaction temperature results in an increase in the period and amplitude of the pH oscillations. Furthermore, it is observed that during oscillations at any specific temperature, the time taken for pH to increase from a minimum to a maximum value varies with respect to reaction time. However, the time required for the pH to fall from maximum to new minimum is approximately constant with respect to the reaction time and is a function of the reaction temperature.

Rehabilitation needs of combat-injured service members admitted to the VA Polytrauma Rehabilitation Centers: the role of PM&R in the care of wounded warriors.

OBJECTIVE: To describe the rehabilitation course of combat-injured service members who sustained polytraumatic injuries during the current wars in and around Iraq and Afghanistan. DESIGN: Retrospective descriptive analysis. SETTING: Department of Veterans Administration Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS: One hundred eighty-eight consecutive, acutely combat-injured service members suffering polytraumatic injuries requiring inpatient rehabilitation and being treated at PRCs between October 2001 and January 2006. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Medications prescribed, devices used, injuries and impairment information, and consultative services. RESULTS: Ninety-three percent of the patients had sustained a traumatic brain injury (TBI) and more than half of these were incurred secondary to blast explosions. Over half of the patients had infections or surgeries prior to PRC admission that required continued medical attention during their stay. Pain and mental health issues were present in 100% and 39%, respectively, of all patients admitted and added complexity to the brain injury rehabilitation process. Common treatment needs included cognitive-behavioral interventions, pain care, assistive devices, mental health interventions for both patients and their families, and specialty consultations, in particular to ophthalmology, otolaryngology, and neurology. CONCLUSIONS: Combat-injured polytrauma patients have complex rehabilitation needs that require a high level of specialized training and skill. Physical medicine and rehabilitation specialists treating war injured service members need a high level of expertise in assessment and treatment of co-occurring pain, TBI, and stress disorders. Physiatrists are playing an important role in providing and coordinating the rehabilitation care for individuals with significant polytraumatic war injuries from the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) conflicts.

Design of a new optical system for Alcator C-Mod motional Stark effect diagnostic.

The motional Stark effect (MSE) diagnostic on Alcator C-Mod uses an in-vessel optical system (five lenses and three mirrors) to relay polarized light to an external polarimeter because port access limitations on Alcator C-Mod preclude a direct view of the diagnostic beam. The system experiences unacceptable, spurious drifts of order several degrees in measured pitch angle over the course of a run day. Recent experiments illuminated the MSE diagnostic with polarized light of fixed orientation as heat was applied to various optical elements. A large change in measured angle was observed as two particular lenses were heated, indicating that thermal-stress-induced birefringence is a likely cause of the spurious variability. Several new optical designs have been evaluated to eliminate the affected in-vessel lenses and to replace the focusing they provide with curved mirrors; however, ray tracing calculations imply that this method is not feasible. A new approach is under consideration that utilizes in situ calibrations with in-vessel reference polarized light sources.